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DERMOCHROMES 


SIXTH   REVISED    EDITION 


PORTFOLIO 

OF 

DERMOCHROIVIES 

BY 

JEROME    KINGSBURY,    M.D. 

ATTEXDING   PHYSICIAN    KEW   TOBK    SKIN    AND    CANCER    HOSPITAL;    PHYSICIAN    FOB    DISEASES 

OF  THE   SKIN   TO   THE  PRESBYTERIAN    HOSPITAL   DISPENSARY;     MEMBER   OF   THE 

AMERICAN   DEBMATOLOGICAL    ASSOCIATION;     MEMBER    OF    THE    NEW 

YORK    DERMATOLOOICAL    SOCIBHT,   ETC. 

CHAPTERS  Oy  8TPBILI8 

BY 

WILLIAM    GAYNOR    STATES,    M.D. 

ASSISTANT   SURGEON    NEW   YORK    POLYCLINIC    HOSPITAL;    FORMERLY   INSTRtJCTOB   IN    QENTTO- 

L'BINARY    AND    VENEREAL    DISEASES;     MEMBER    OF    THE    AMERICAN     MEDICAL 

ASSOCIATION;     MEMBER    OF    STATE    AND    COUNTY     MEDICAL    SOCIETY 

OF  NEW  YORK,  WEST  SIDE  CUNICAL  SOCTETY,  ETC. 

WITB  TWO  nUXDRED  AXD  8IXTTSIX  COLORED  ILLCSTRATIOyS 
AyO  SIX  BALFTOyE  FIOVRES 

Volume  I 


NEW    YORK 
REBMAN     COIVIPANY 

herald  square  bliloing 
141-145  West  36th  Street 


All  Rights  reserved 

COPYRIOHT,   1921,  BY 

REBMAN    COMPANY 
New  Yobk 


PRINTED   IN  AMERICA 


Preface 

This  Portfolio  of  Dcrmochromes  contains  two  hundred  and  sixty- 
six  colored  and  six  black  and  white  illustrations.  All  of  the  colored 
plates  are  from  Jacobi's  "Atlas  der  Hautkrankheiten "  and  two  hun- 
dred and  seventeen  of  the  figures  appeared  in  the  fourth  American 
edition  of  this  work,  known  here  as  the  Jacobi  Dermochromes.  Tho  re- 
maining forty-nine  figures  are  from  the  fifth  Geniian  edition  of  tho 
Atlas  and  are  now,  by  arrangement  with  the  German  publisher,  pre- 
sented for  the  first  time  in  this  country.  The  black  and  white  illustra- 
tions, representing  different  types  of  alopecia,  are  from  photographs 
taken  for  me  by  Dr.  William  B.  Trimble. 

Although  many  of  the  plates  will  be  familiar  to  Amorioan  phy- 
sicians, the  accompanying  text  is  entirely  new.  In  its  preparation  the 
writings  of  the  leading  American,  British,  and  Continental  denna- 
tologists  have  been  freely  consulted,  but  preference  has  generally  been 
given  to  the  views  of  the  fonner,  as  the  work  is  intended  chiefly  for 
readers  in  tliis  country.  I  particularly  desire  to  acknowledge  manifold 
obligations  to  Drs.  Bulkley,  Duhring,  Pusey,  and  Stclwagon. 

The  section  on  syi^hilis  was  intrusted  to  Dr.  William  Gaynor  States, 
and  I  greatly  appreciate  the  honor  of  having  his  able  presentation  of 
this  disease  incorporated  in  this  work. 

To  my  clinical  associates  at  the  New  York  Skin  and  Cancer  Hos- 
pital I  am  indebted  for  considerable  assistance ;  to  Dr.  Paul  E.  Beehet 
and  Dr.  Arthur  M.  Kane  for  valuable  aid  in  preparing  the  manuscript 
and  in  passing  the  work  through  the  press,  and  to  Dr.  Biuford  Throne 
for  the  excellent  chapters  on  the  exanthemata.  I  here  take  pleasure  in 
expressing  to  them  my  tlianks  for  their  generous  cooperation. 

The  subjects  have  been  grouped,  as  far  as  practical,  according  to 
generally  accei)ted  pathological  classifications,  jind  with  but  few  excep- 

r 


tlons  the  nomenclature  recommended  by  the  American  Dermatological 
Association  has  been  adhered  to  in  the  text. 

"While  fully  realizing  that  in  a  work  of  this  scope  individualism  is 
out  of  place,  I  must  confess  that  I  have  not  always  refrained  from  the 
temptation  to  interject  personal  impressions  and  opinions. 

JEROME  KINGSBURY. 


Plate      Fig. 


List  of  Plates 

Text  Page 


*  >  Erythema  multiforme    

1  2^       ^ 

^  [  Erythema  iris 

2  4j       ^  6 

3  5    Erythema  nodosum   

^  >  Purpura  hemorrhagica 

4  1) 

^  >  Herpes  progenitalis 

5  9)  .      ,  14. 

5  10    Herpes  smiplex 

i;  11)  ,  16 

2  ,„>  Herpes  zoster 

7  12^  .  19 

7  13    Pompholyx  (Dysidrosis)   ^^ 

8  14.    Impetigo  contagiosa ^4, 

9  16    Hydroa  vacciniformis   ^g 

10  16   Pemphrigus  vulgaris ^9 

11  17    Pemphigus  foliaceus ^^ 

12  18    Pemphigus  vegetans gg 

13  19    Pemphigus  neonatorum 

13  ^H  Dermatitis  herpetiformis 

14  21^  ^  38 

15  22    Urticaria    g^^ 

16  23    Urticaria  chronica  infantum    ^^ 

17  24.    Urticaria  rubra gg 

17  25    Urticaria  pigmentosa • ^^ 

18  26    Antipyrine  rash \    '      ^g 

18  27    Arsenic  rash I '  '      ^^ 

19  28    Copaiba  rash I 

20  29    Bromine  rash V  Dermatitis  Medicamentosa ...      44 

20  30j       jj^^^3h (  ** 

21  3lJ  \  44 

21  32    Chloride  rash I ^5 

22  83    Mercury  rash / 

vii 


Plate  Fig.  Text  Page 

23  84    Lichen  simplex  chronicus  ( I'idal)    46 

23  35    Pityriasis  rubra  pilaris 47 

24  36    Eczema  acutum  cum  pigmentatione    49 

24  87    Eczema  folliculare 49 

25  38    Eczema  madidans    49 

26  39    Eczema  crustosum  mamnjje    49 

26  40    Eczema  crustosum  axillae 49 

27  41    Eczema  orbiculare  oris 49 

27  42    Eczema  e  professione 49 

28  43    Eczema  chronicum  squamosum 49 

28  44"! 

29  45  \^  Eczema  chronicum  corneum 49 

29  46j 

30  47^^       .  _« 

31  49    Lichen  planus    69 

31  50    Lichen  planus  atrophicus 69 

32  51    Lichen  planus  verrucosus 69 

33  52    Lichen  planus  annularis 69 

33  53    Lichen  planus  mucosa;  oris 59 

34  64    Psoriasis  gyrata  et  serpiginosa 63 

35  55    Psoriasis  vulgaris  guttata  et  ostracea 63 

35  66] 

36  67 1 

36  68  \  Psoriasis  vulgaris 63 

37  69 1 

37  60j 

38  61    Psoriasis  vulgaris  unguium 63 

38  62    Psoriasis  vulgaris  rupioides   63 

39  63] 

40  64  ^  Eczema  seborrhoicum    69 

40  65j 

41  66    Alopecia  from  eczema  seborrhoicum   70 

42  67    Perniones    72 

42  68    Raynaud's  disease 73 

43  69    Gangrcna  diabetica 75 

44  70    Ecthyma  gangrenosum   76 

45  71    Ulcer  from  Roentgen  Rays    78 

46  72)  „  ,,  7q 

48  74    Varicella 87 

viii 


PlUTT  FlO.  TlXT    PAOr 

48  "75  Variola  discreta 82 

49  76  Variola    82 

49  77   Varicella  in  adult 87 

50  78  Varicella   87 


51       79 
51       80 


Vaccinia 89 


52       81 
52       82 


[MorbilH 91 

53       83  Rubella 94 

55   85  r^'^'"'**'"* ^^ 

55  86  Erysipelas 100 

56  87  Exfoliatio  areata  lingua; 103 

56  88  Leukoplakia 105 

57  89  Lingua  scrotalis 107 

57  90  AphthK 108 

58  91   stomatitis  niercurialis    110 

58  92  Dyschromia  gingivje  satumina 112 

59  93  Miliaria  rubra 113 

60  94  Folliculitis  barbte 114 

60       95  Acne  varioliformis 116 

Ij.        q^^Acne  vulgaris 118 

62       98  Acne  rosacea 1 24 

62  99  Rhinophyma 128 

63  100  Dermatitis   papillaris  capillitii    129 

63  101   Granulosis  rubra  nasi 130 

64  102  Alopecia  areata    131 

65  103  Alopecia  congenita 136 

66  104  Vitiligo   138 

66  105  Chloasma 140 

67  106  Na?vus  vascularis 142 

67  107  Na;vus  linearis    144 

68  108  Njbvus  papillaris  pigmentosus 145 

69  109  Nffvus  pigmentosus  (sarcoma) 145 

69  110  Adenoma  sebaceum 147 

70  111   Ichthyosis  simplex 148 

71  112  Ichthyosis  hystrix    150 

72  113  Ichthyosis  congenita 152 

72  114   Keratosis  pilaris 153 

73  115  Fibroma  molluscum    155 

iz 


16  Dermatomyoma  multiplex 156 

17  Verrucae  vulgares , 157 

18  Papillomata  (condylomata  acuminata) 159 

19  Verrucas  seniLes  (cavernomata  senilia)    161 

20  Keratosis  senilis 162 

21  Xeroderma  pigmentosum 163 

22  Keratosis  follicularis   164 

23  Elephantiasis  penis  et  scroti 166 

24"! 

25  [Scleroderma   167 

26j 

27  Atrophia  cutis  idiopathica 170 

28  Striae  distensjE 172 

29  Molluscum  contagiosum 173 

30  Keloid 176 

31) 

ac,  \  Xanthoma  tuberosum  multiplex 177 

33  Xanthoma  palpebrarum 179 

34  Atheroma  multiplex  (cystes  sebaceae) 180 

35] 

36 

37  [-Lupus  erythematosus 182 

38 
39 

40  Lupus  pernio 187 

41  Lupus  vulgaris  incipiens 188 

42  Lupus  vulgaris  verrucosus    188 

43  Lupus  vulgaris 188 

44  Lupus  vulgaris  (comu  cutaneum) 188 

45  Lupus  vulgaris  (epithelioma) 188 

46  Lupus  vulgaris 188 

47  Lupus  vulgaris  serpiginosus 188 

48  Lupus  vulgaris  (elephantiasis  consecutiva) 188 

49  Lupus  vulgaris  (mutilatio) 188 

50  Lupus  vulgaris  hypertrophicus 188 

51  Lupus  vulgaris 188 

52  Lupus  vulgaris  mucosae  oris 188 

53  Verruca  necrogenica 193 

54  Tuberculosis  linguae 195 

55  Tuberculosis  nasi 196 

56  Lichen  scrophulosorum 197 


113 
114 


P""       F'°-  TrxT  Pace 

96  157  Erythema  induratum  scrophulosorum  (Bazin) 199 

97  158  Scrophuloderma 201 

97  159  Papulo-necrotic  tuberculide 203 

98  160  Ulcus  endemicum  tropicum 205 

99  161] 

99  162 It  .   , 

,  „^            ^Lcpra  tubcrosa 206 

100  164.J 

101  165  Lepra  anaesthetica   208 

102  166  Lepra  (ulcus  pcrforans) 208 

102  167  Rliinoscleroma 212 

103  168  Leukaemia  cutis 214 

104  169)  „         ,  ,         ., 

105  i'~Q("'"*nuloma  fungoides 216 

105  171   Sarcoma  idiopatliicum  multiplex  hasmorrhagicum 219 

106  172  Sarcomatosis  cutis 219 

107  173|.,,  , 

107  174)            rodens 221 

108  175  Paget's  disease  of  the  nipple 224 

109  176  Carcinoma  lingua? 226 

109  177  Carcinoma  penis 228 

110  178  Carcinoma  cutis 229 

111  179)„.        , 

111  180)  ^'"*^*  favosa 230 

112  181  Alopecia  from  favus 230 

182)     . 

■joo^Tmea  trichophytina  capitis 233 

115  is-i! 

116  1 85  >  Tinea  trichophytina  corporis 237 

116  186) 

117  187  Tinea  trichoph3'tina  unguium 240 

117  188  Tinea  barba; 242 

lis  189  Tinea  versicolor 244 

119  190  Erythrasma    246 

119  191    Pityriasis  rosea 248 

120  192  Anthrax  (pustula  maligna) 251 

120  193  Actinomycosis  cutis   253 

121  194? 

121  195 (Sporotrichosis 255 

122  196  Sporotrichosis  verrucosa 255 

122  197  Sporotrichosis  epidemica 255 


zi 


Plate  Fio.                                                                                                                      Text  Paos 

123  198] 

124  199  ^Scabi'es    ., 258 

124  200j 

125  201   Pediculosis  capitis  (eczema  inipetiginosum ) 263 

125  202  Pediculosis  vestimentorum 265 

126  203  Melanodermia  e  pediculis  vestimentorum 265 

126  204  Maculse  ceruleje  (ulcus  molle  elevatum — bubo  inguinalis).  .  267 

127  205  Myiasis  linearis    269 

127  206  Onychogryphosis    271 

1 2R  onof  Alopecia  syphilitica 323 

129  209] 293 

129  210  ^Scleroses  syphilitica 294 

130  21lJ 302 

130  212  Sclerosis  phagedasnica    302 

131  213  Sclerosis  labii  majoris 295 

131  214  Sclerosis  et  edema  indurativum   (in  infants) 295 

132  215" 


132  216 

133  217 


►  Scleroses  Syphilitica 298 

293 


133  218j 

134  219  Sclerosis  syphilitica  tonsillae   298 

135  220  Syphilis  maculosa  (roseola)    308 

136  221   Syphilis  maculosa  conflucns  (leukoderma) 309 

137  222  Syphilis  maculosa  recidiva  (roseola  recidiva) 309 

138  223   Syphilis  maculosa  follicularis 309 

138  224  Syphilis  papulosa  annularis 309 

139  225  Syphilis  papulosa  lenticularis 310 

139  226  Syphilis  papulosa  mucoss  oris   310 

140  227  Syphilis  papulosa  orbicularis    310 

140  228  Syphilis  papulo-squamosa 311 

141  229  Syphilis  corymbiformis    314 

142  230  Syphilis  milio-papulosa  (lichenoides) 311 

142  231   Syphilis    circinaria    314 

143  232  Syphilis  papulo-pustulosa 315 

143  233  Syphilis  papulo-squamosa 315 

144  234  Paronychia  syphilitica 322 

144  235  Leucoderma  sypliiliticum 322 

145  236  Syphilis  papulosa  (condylomata  lata) 325 

146  237  Syphilis  papulosa  mucosas  et  anguli    oris 328 

146  238  Syphilis  papulosa  linguae 315 

xii 


Plate  !■  io.                                                                                                                             Text  PaM 

147  239  Syphilis  papulosa    315 

148  ~iO   Syphilis  papulosa  (condylomata  lata) 326 

148  Sll   Syphilis  papulo-pustulosa 318 

149  242   Syphilis  nmlignn  (rupia  syphilitica)    341 

149  243  Syphilis   franiboesifomiis    320 

150  244  Syphilis  tuboro-serpiginosa   839 

150  245  Syphilis  tertiaria 339 

151  246  Syphilis  tubcro-serpiginosa 339 

151  247  Syphilis  ulcero-serpigiiiosa    339 

152  248  Cicatrices  palati  mollis  post  ulcerationes  syphiliticas 350 

152  249  Caries  syphilitica  ossium  cranii    336 

153  250  Syphilis  ulcerosa  palati  molHs   350 

153  251   Syphilis  ulcerosa  palati  duri 350 

154  252  Syphilis  gummosa  lingua;  diffusa 348 

154  253  Syphilis  ginnmosa  digiti 348 

155  254  Syphilis  gummosa 349 

155  256   Syphilis  gummosa  glandis   (pseudo-chancre) 303 

156  256)  „      ....  .,, 
1  'ifi     257  \  •^yP'""^  gummosa 347 

157  258  Syphilis  ulcero-serpiginosa 351 

IKft     0«f»l  ^yP'^'''*  I'creditaria  bullosa  (peiiiphigua  syphiliticus) 335 

159  261] 

160  262  ^Syphilis  hereditaria  papulosa 354 

160  263  J 

161  264  Syphilis   hereditaria  ossium   nasi    355 

161  265  Hutchimon  teeth 355 

162  266  Syphilis  hereditaria  tarda 357 

163  267  Ulcus  molle  orificii  urethrae 369 

163  268  Ulcus  molle  digiti    367 

164  269  Ulcera  mollia  (bubonulus)    369 

164  270  Ulcus  molle  gangrenosum 370 

165  271   Ulcera  mollia  vulva; 368 

165     272  Ulcus  molle  phagedtenicum 303,  370 


Alphabetical   List  of   Figures 

(The  Numbers  quoted  are  tlie  pages  of  the  Text  on  which  reference  to  the 

Figures  is  made) 

PAGE 

Acne  keloid 129 

rosacea    12'! 

varioHformis     116 

vulgaris     118 

Actinomycosis  cutis 253 

Adenoma  sebaceum    147 

Alopecia  adnata 136 

areata     131 

congenita    136 

syphilitica     323 

Anthrax    251 

Antipyrin  rash 43 

Aphthae     108 

Arsenic  rash 43 

Atheroma  multiplex 180 

Atrichia,  universal   congenital    136 

Atrophia  cutis  idiopathica 170 

Bazin's  disease 199 

Body  lice    267 

Bromine  rash 44 

Carcinoma  cutis 229 

lingu»   226 

penis    228 

Caries  syphilitica  ossium  cranii 336,  252 

Chancre,  hard    291 

mou     367 

soft   367 

syphilitic     291 

Chancrelle    367 

Chnncroid     ....  367 

Chancroide   367 

xiv 


PAGE 

Cliciro-pompholyx     19 

Chickcnpox     87 

Cliilblrtins    72 

Cliloiisiiia    140 

Chlorine  rash 44! 

Cicatrices  palati  mollis  post  ulccrationes  syphiliticas 350 

Condyloniata  acuminata    159 

Copaiba  rash    44 

Crab  lice    267 

Dermatitis  contusiformis 6 

herpetiformis    .35 

medicamentosa    42 

papillaris  capillitii     129 

pruriginosa 35 

seborrheica 67 

Dermatomyoma  multiplex 156 

Diabetic  gangrene    75 

Duhring's  disease 35 

Dyschromia  gingivse  saturnina 112 

Dysidrosis     19 

Ecthyma  gangrenosum   76 

Eczema  49 

scborrhoicum    69 

Elephantiasis  Grccorum    206 

penis  et  scroti 166 

Erysipelas     100 

Erythema  induratum  scrophulosorum 199 

iris     4 

multiforme    1 

nodosum    6 

pernio    72 

Eryth^me  nouvcux 6 

Erythrasma    246 

Exfoliatio  areata  lingua* 103 

Favus    230 

Fibroma  molluscum 155 

Folliclis     203 

Folliculitis  barbae 114 

Gangrene,  diabetic 75 

Geographical  tongue   103 

Gcnnan  measles    94 

Gibert's  disease    248 

XV 


PAGE 


Granuloma  fungoides 216 

Granulosis  rubra  nasi   130 


Herpes  facialis 14 

genitalis    11 

iris    4 

labialis     14 

preputialis    11 

progenitalis     11 

simplex    14 

zoster      16 

Hives     38 

Hutchinson    teeth    355 

Hydroa  »stivale 24 

herpetiformis    35 

vacciniforme 24 

Ichthyosis  congenita 152 

hystrix    150 

simplex    148 

Impetigo  contagiosa    21 

Iodide  rash 44 

Itch 258 

Keloid     175 

Keratosis  follicularis 164 

pilaris   153 

senilis    • 162 

Leontiasis   206 

Lepra    206 

Leprosy     206 

Leucoderma    138 

syphiliticum    322 

Leukemia  cutis 214 

Leukopalkia    105 

Lichen  pilaris 153 

planus 59 

scrofulosorum    197 

simplex  chronicus  Vidal 46 

tropicus    113 

Lingua  scrotalis 107 

Lupus  erythematosus 182 

pernio    187 

vulgaris     188 

xvi 


FACE 

Maculaj  cerule«    267 

Measles 91 

Mercury  rash 45 

Miliaria  rubra    113 

Molluscum  contiigiosuiii     173 

fibrosum    155 

pendulum     155 

Morbilli     91 

Myiasis  linearis    269 

N£e^■us  linearis   144 

papillaris  pignicntosus 1 45 

vascularis    142 

Necrotic  granuloma 208 

Nettle  rash 38 

Neurodcrmititis    46 


Onychogryphosis    271 

Onychomycosis     240 


Paget's  disease  of  the  nipple 224 

Papillomata    159 

Papulo-necrotic   tuberculide    203 

Paronychia   syphilitica    322 

Pediculosis  capitis    263 

pubis 267 

vestimentorum    265 

Pellagra    79 

Pemphigus    foliaceus    29 

neonatorum   33 

vegetans    31 

vulgaris     26 

Pernio 72 

Phthisiasis  capitis    263 

Pityriasis  lingua; 103 

niaculata  et  circinata    248 

rosea     248 

rubra  pilaris ^1 

Pompholyx 19 

Post-mortem  wart   198 

Prickly  heat 118 

Prurigo      57 

Pscudochancre    303 

Psoriasis    63 

Purpura  hemorrhagica    9 

Pustula  maligna     251 

xvii 


PAGE 

Quinine  rash 45 

Raynaud's  disease    73 

Rhinophyma 128 

Rhinoscleroma    212 

Ringworm  of  the  body    237 

nails    240 

Roentgen  ray  ulcer 78 

Roethcln    94 

Rubella 94 

Rubeola     91 

Sarcoma  cutis    219 

Satyriasis    206 

Scabies    258 

Scarlatina     96 

Scarlet  fever 96 

Schanker 367 

Scleroderma    167 

Sclerosis  et  edema  indurativum  (in  infants)    295 

labii  majoris 295 

phagedenica 302,  351 

syphilitica    293,  297,  300,  302 

tonsillae   298 

Scrophuloderma    201 

Seborrheic  eczema    67 

Shingles    16 

Smallpox     82 

Spedalskhed    206 

Sporotrichosis    255 

Stomatitis  mercurialis   110 

Striae  distensje    172 

Sycosis,  non-parasitica   114 

Syphilides,  moist   324 

papular     310 

tertiary     332 

tubercular     337 

Syphilis     273 

circinaria    314 

corymbifonnis    314 

framboesiformis     320 

gummosa     347,  349,  351 

digiti 347 

glandis    303 

hereditaria  bullosa 354 

papulosa 354 

tarda     351 

xviii 


PACE 

Syphilis,  hereditary 351 

niJiculosii   ( roscohi)    308 

confluens  (leukoderma)    309 

follicuhiris     309 

recidiva     309 

maligna 341 

milio-papulosa  (lichenoides)    311 

papulosa    315,  326 

(condylomata  lata)    325 

lenticularis    310 

mucosa;  et  anguli  oris 328 

orbicularis    310 

papulo-pustulosa     318,  354 

squamosa     311,  315 

tertiaria    339 

tubero-serpiginosa    339 

ulcerosa  palati  mollis 350 

ulcero-serpiginosa 335,  352 

Syphilodenna   306 

Tinea  barbfe   242 

circinata 237 

favosa   230 

trichophytina  capitis 233 

corporis    237 

unguium    240 

versicolor    244 

Transitory  benign  plaques  of  the  tongue 103 

Tuberculosis    linguas 195 

nasi   196 

Ulcer  from  Roentgen  ray 78 

simple  venereal 367 

T'lccra  moUia  (bubonulus)    369 

vulvas 368 

Ulcero  molle 367 

Ulcus   endcmicum   tropicum    205 

molle     355.  367 

digiti   367 

gangrenosum    370 

orifJcii  urethrw    355,  369 

phagednenicum     370 

rodens     221 

Urticaria    38 

Vaccinia    S9 

Vagabond's  disease    265 


PAGE 

Varicella 87 

Variola    82 

Verruca  necrogenica    193 

Verrucae  seniles 161 

vulgares     157 

Vitiligo   138 

Warts,    common    157 

senile     161 

Xanthoma  palpebrarum    179 

tuberosum  multiplex 177 

Xeroderma  pigmentosum 163 

Zona    16 

Appendix    378 

Index    , 379 


XX 


Plate  1. 


Fig.  1 .  2.  Erythema  multiforme. 


Erythema  Multiforme 

Plate  1,  Figs.  1  and  2 

Erythema  multiforme  is  an  acute  dermatosis  having  certain  affin- 
ities with  urticaria  and  purpura  and  hence  believed  to  be  essentially 
angioneurotic  in  character  and  dependent  on  some  irritant  within  the 
blood  which  is  chiefly  of  intestinal  origin.  It  differs  from  an  ordinary 
toxic  rash  in  the  large  amount  of  infiltration,  and  in  its  appearance  in 
successive  crops.  "While  eminently  multiforme,  in  the  majority  of 
cases,  the  lesions  are  more  or  less  uniform  in  that  there  is  a  predom- 
inant type.  The  affection  differs  from  those  which  most  resemble  it  in 
a  tendency  to  appear  in  certain  localities,  as  the  upper  extremities 
below  the  elbows,  the  legs  and  feet  and  the  face.  It  prefers  the 
exterior  surfaces,  as  a  rule.  In  certain  cases  the  entire  surface  of 
the  body  may  be  involved,  and  even  some  of  the  adjacent  mucous 
membranes.  Unlike  most  acute  eruptions,  it  gives  rise  to  little  sub- 
jective discomfort. 

A  constitutional  reaction  from  the  eruption  or  in  association  with 
it  seldom  occurs,  but  erythema  multiforme  may  represent  a  manifesta- 
tion of  some  general  infection  which  is  akin  to  acute  rheumatism.  In 
occasional  cases  there  is  serious  organic  disease  of  the  abdominal 
organs.  These  modes  of  behavior  make  it  appear  probable  that  the 
affection  is  a  syndrome  and  not  an  actual  disease. 

The  conunonest  form  is  a  papular  efflorescence,  the  lesions  of 
which  do  not  exceed  the  size  of  a  large  pea.  The  papules  may  be  dis- 
crete or  aggregated.  Less  common  are  tubercles  which  are  consider- 
ably larger  and  accompany  the  smaller  lesions.  All  these  lesions  tend 
to  flatten  and  broaden  and  leave  a  depression,  so  that  a  ring  may  be 
formed.  The  color,  a  dark  vinous  red,  is  almost  characteristic.  Some- 
times rings  of  considerable  size  are  formed,  and  segments  of  rings 
may  be  combined  to  form  certain  patterns;  or  one  ring  may  form 
within  another.  In  severe  cases  a  papule  or  tubercle  may  have  a 
vesicular  centre.    Aside  from  this  there  is  a  typical  vesicular  form 


known  as  erythema  iris  which  will  be  described  later.  Bullous  and 
purpuric  forms  bear  a  close  resemblance  to  pemphigus  and  purpura 
and  perhaps  tend  to  partake  of  the  nature  of  those  affections. 

Etiology 

As  already  stated,  the  affection  appears  to  be  a  syndrome  which 
may  be  due  to  a  great  variety  of  causes — ^various  circulating  poisons, 
some  of  which  may  be  the  product  of  intestinal  autointoxication.  The 
affection  may  sometiines  appear  as  an  equivalent  to  an  attack  of 
dermatitis  medicamentosa,  and  at  times  it  is  doubtless  the  result  of  a 
bacteriotoxemia.  It  is  a  disease  of  relatively  early  years  and  fre- 
quently attacks  unacclimated  subjects.  Its  most  salient  anatomical 
feature  appears  to  be  the  cell  proliferation  which  gives  the  peculiar 
fixed  character  to  the  lesions. 

Diagnosis 

The  disease  most  closely  resembles  urticaria  when  the  wheals  of 
the  latter  are  red.  Urticarial  lesions,  however,  are  very  fugacious, 
accompanied  by  much  itching  and  burning,  and  seldom  form  rings. 
The  latter  when  highly  developed  suggest  ringworm,  but  this  can 
hardly  appear  as  a  more  or  less  extensive,  symmetrical  eruption. 
While  erythema  nodosum  may  coexist,  there  should  be  no  confusion, 
for  although  the  two  affections  have  much  in  common,  their  lesions 
are  quite  dissimilar. 

Prognosis 

If  the  affection  be  regarded  as  a  syndrome,  the  prognosis  will  de- 
pend on  the  actual  cause  of  the  disease.  The  eruption  subsides  com- 
pletely in  two  or  three  weeks,  but  some  cases  tend  to  recur  at  short 
intervals. 

Treatment 

The  bowels  should  first  be  well  evacuated,  and  after  this  intestinal 
antiseptics  and  antirheumatic  medication  administered.  Capsules  of 
salol  gr.  v.,  three  or  four  a  day,  are  useful,  and  frequent  and  mod- 
erately large  doses  of  quinine  are  at  times  of  service.  If  rheumatic 
symptoms  are  at  all  marked  salicylate  of  soda  should  be  given  in  full 
doses.  There  is  but  little  local  treatment  required,  as  the  lesions  soon 
run  their  course  and  give  rise  to  but  little  disturbance.  In  some 
cases,  however,  the  itching  and  burning  are  quite  troublesome,  and  for 


one  that  is  generally  found  satisfactory : 

these  cases  antipruritic  lotions  may  be  prescribed.    The  following  is 

^  Acidi  carbolici    Sss. 

Magnes.  carbonat 3i 

Zinci  oxidi 3i 

Aquae  rosa; ^iv 

M.  et  ft.  lotio. 


Figs.  1  and  2.     Models  in  Neisser's  Clinic  in  Breslau  {Kroener), 

8 


Erythema  Iris 

Synonym:   Herpes  iris 
Plate  2,  Figs.  3  and  4 

Whether  this  eruption  is  a  simple  clinical  variety  of  erythema  mul- 
tiforme or  a  distinct  affection  affiliated  with  it,  was  formerly  a  vexed 
question,  but  at  present  authorities  seem  to  have  decided  upon  the  vir- 
tual identity  of  the  two.  There  may,  however,  be  as  good  reasons  for 
the  dualistic  view  in  the  case  of  erythema  iris  as  in  erythema 
nodosum. 

In  erythema  iris  we  see  a  particular  type  of  erythema,  attended  in 
the  great  majority  of  cases  with  vesiculation ;  so  that  the  former  may 
be  regarded  as  an  abortive  phase.  In  other  forms  of  erythema  multi- 
forme vesiculation  is  exceptional.  The  process  of  vesiculation  in 
erythema  iris  also  resembles  that  of  true  herpes,  for  the  vesicles  ap- 
pear promptly  and  with  the  same  stinging  sensation.  Moreover,  it  is 
sometimes  seen  in  association  with  herpes  facialis  and  herpes  pro- 
genitalis. 

Erythema  iris  consists  of  concentric  rings  of  erythema,  which, 
like  other  lesions,  run  their  course  rapidly,  and  since  the  rings  appear 
in  succession,  exhibit  different  shades  of  color  suggestive  of  the 
deeper  hues  of  the  rainbow — bright  red,  purple  and  violet,  the  older 
rings  being  of  the  latter  shades.  In  this  process  the  new  rings  form 
outside  of  the  old  ones,  developing  from  a  red  areola ;  and  the  nmnber 
may  vary  from  two  to  six.  As  already  stated,  the  process  of  vesicula- 
tion begins  early,  within  twelve  hours,  so  that  lesions  of  different 
degrees  of  development  appear  side  by  side.  From  the  formation  of 
concentric  rings,  large  patches  are  formed  and  may  coalesce. 

The  vesicles  are  essentially  small  but  coalesce  in  the  rings,  and  ex- 
ceptionally the  central  vesicle  may  form  a  bulla  of  variable  size  with 
which  the  outside  vesicles  may  coalesce.  The  vesicles  last  about  a 
week  and  disappear  by  absorption. 

The  distribution  of  erythema  iris  agrees  mth  that  of  erythema 


Plate  2. 


Fig.  3.  4.  Erythema  Iris. 


multiforme  in  every  respect  in  both  typical  and  exceptional  cases,  and 
the  treatment  presents  no  peculiarities,  save  that  large  bullae  may 
require  evacuation. 


Fig.  3.     Model  in  Neisser's  Clinic  in  Breslau  (Kroencr). 

Fig.  4.  Model  in  Neisser's  Clinic  in  Breslau  {Krocner).  A  repeatedly 
recurrent  vesicular  eruption  in  a  tailoress,  twenty-five  years  of  age, 
with  high  fever  and  joint  symptoms. 


Erythema  Nodosum 

Synonyms:    Dermatitis  contusifonnis.     (Fr.)  Erytheme  nouveux 

Plate  3,  Fig.  5 

This  affection  is  in  many  respects  very  closely  related  to  erythema 
multiforme.  It  possesses,  however,  features  particularly  its  own, 
thus  affording  a  convenient  excuse  to  describe  it  as  a  separate 
disease. 

In  most  text-books  it  is  referred  to  as  an  affection  of  childhood 
and  adolescence,  but  adults  are  by  no  means  immune,  and  I  can  re- 
call, from  my  own  practice,  a  typical  case  that  occurred  in  a  woman 
sixty  years  of  age.  For  some  unknown  reason  the  disease  is  very 
much  more  common  in  females  than  in  males.  The  characteristic  le- 
sions of  erythema  nodosum  consist  of  more  or  less  elevated  node-like 
swellings.  These  occur  most  commonly  over  the  shins,  and  as  a  rule 
both  legs  are  affected.  The  nodes  have  no  well-defined  border,  and  in 
size  they  vary  from  that  of  a  hazel-nut  to  a  mass  sometimes  as  large 
as  a  hen's  egg.  They  are  generally  oval  in  shape,  and  their  long  axis 
corresponds  to  that  of  the  limb.  The  color  is  at  first  bright  red,  but 
soon  blue,  and  then  purplish  tints  appear,  and  as  absorption  pro- 
gresses, it  gradually  fades  to  a  yellowish  hue,  and  at  this  time  the 
lesions  resemble  bruises ;  this  explains  one  of  the  titles  that  has  been 
given  to  this  affection  by  some  authors  (dermatitis  contusiformis). 
The  swellings  when  they  first  appear  are  hard  and  tense,  but  they  be- 
come softer  as  the  inflammation  subsides.  At  times  a  sensation  of 
fluctuation  is  obtained,  but  the  lesions  never  suppurate.  Nodes  not  in- 
frequently occur  on  the  flexor  surface  of  the  legs  and  occasionally  on 
the  thighs,  buttocks,  and  forearms.  The  individual  nodes  last  about 
two  weeks,  but  new  lesions  sometimes  continue  to  appear,  even  in 
cases  that  are  under  treatment,  and  the  duration  of  an  attack  ranges 
from  three  to  six  weeks.  When  the  nodes  first  appear,  they  are  gen- 
erally preceded  and  accompanied  by  a  greater  or  less  degree  of  con- 
stitutional disturbance.  At  times  there  are  symptoms  referable  to 
derangements  of  the  gastro-intestinal  tract,  but  the  most  constant 


Plate  3. 


Fig.  5.  Erythema  nodosum. 


Fig.  6.  Purpura  hemorrhagica. 


concomitant  symptoms  are  tliose  of  acute  articular  rheumatism  of  the 
extremities,  the  lower  being  more  frequently  affected. 

Etiology 

Erythema  nodosum  is  so  frequently  associated  with  dofinito  rheu- 
matic symj)toms,  that  it  is  now  very  generally  looked  upon  as  an  ex- 
pression of  rheumatism. 

Diagnosis 

This  is  seldom  difficult,  but  at  times  the  resemblance  of  inflamed 
syphilitic  gummata  to  the  lesions  of  erythema  nodosum  is  quite 
marked.  In  sj-philis,  however,  the  development  of  the  lesions  is  more 
indolent,  their  number  less,  and  they  are  not  likely  to  be  accompanied 
by  constitutional  sj-mptoms.  In  complicated  cases  the  Wassermann 
or  the  Noguchi  reaction  should  be  of  considerable  assistance. 

Occasionally  cases  of  erythema  induratum  are  confused  with  those 
of  erythema  nodosum,  but  the  former  affection  is  a  more  chronic  one, 
the  lesions  are  much  smaller,  are  generally  found  on  the  calf  of  the 
leg,  and  even  in  comparatively  recent  cases  there  is  generally  either 
ulceration  or  evidence  of  beginning  central  necrosis.  In  erythema 
induratum  a  positive  tuberculine  reaction  is  invariably  obtained. 

Prognosis 

This  is  favorable  as  far  as  the  disappearance  of  the  lesions  is  con- 
cerned, but  their  development  should  be  looked  upon  not  only  as  an 
evidence  of  rheumatism  but  of  impaired  vitality  as  well,  and  the  pos- 
sibility of  an  already  existing  endocarditis  should  be  ascertained. 

Treatment 

If  the  swellings  are  very  painful  and  the  rheumatic  symptoms  se- 
vere, it  is  advisable  to  have  the  patient  remain  in  bed  for  a  few  days 
or  a  w^eek.  Although  desirable,  this  is  seldom  absolutely  necessary. 
The  diet,  however,  should  be  restrictive,  especially  so  if  the  febrile 
sjTnptoms  are  at  all  marked.  In  adults  the  bowels  should  be  well 
moved  by  calomel,  followed  by  the  usual  saline,  but  with  children  a 
dose  of  castor  oil  may  be  substituted.  Although  some  observers  have 
questioned  its  rheumatic  relationship,  it  is  a  clinical  fact  that  in 
erythema  nodosum  better  results  are  obtained  with  antirheumatic 
medication  than  with  any  other. 

In  mild  cases,  three  to  eight  grains  of  aspirin  or  salicin  in  capsules 
may  be  given  three  or  four  times  a  day,  but  in  cases  where  the  rheu- 


matic  symptoms  are  well  defined  it  is  better  to  administer  full  doses 
of  the  salicylate  of  soda,  preferably  in  a  mixture.  The  following  for- 
mula is  most  efficacious : 

IJ  Potassii  acetatis oiii 

Sodii  salicylatis   3iv 

Tinct.  nuc.  vomicas   oil 

Syr.  zingiber ad  §iii 

M.  et  ft.  mist. 

Signa  Si  in  water  after  meals. 

After  the  swellings  have  disappeared,  tonic  doses  of  quinine  may 
be  given.  For  the  anaemia  that  is  frequently  present  iron  and  arsenic 
is  indicated.    The  following  is  a  valuable  mixture : 

]J  Ferri  et  ammon.  citrat 9  ii 

Liq.  potassii  arsenitis 3i 

Liq.  potasssB 3iss. 

Vini  ferri  dulcis ad  ^iii 

M.  et  ft.  mist. 

Signa  3i  in  water  after  meals. 

Local  applications  are  seldom  necessary,  but  in  the  acute  stage  if" 
the  nodes  are  particularly  painful  relief  may  be  obtained  from  com- 
presses of  ice,  cold  water,  or  of  lead  and  opium  wash. 


Fig.  6.     Model  in  Lesser's  Clinic  in  Berlin  (Kolbow).     Woman,  thirty-six 
years  old,  without  joint  symptoms,  treated  as  an  out-patient. 

8 


Plate  4. 


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bio 


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CD 


3 

a. 


Purpura  Hemorrhagica 

Plate  3,  Fig.  G;  and  Plate  4,  Fig.  7 

This  affection  is  an  unsatisfactory  one  to  discuss  because  purpura 
is  a  generic  term  for  all  hemorrhages  of  the  skin,  and  thus  in  a  sense 
all  purpura  is  hemorrhagic.  The  term  was  originally  applied  to 
morbus  maculosus  WerDiolii  or  land  scurvy,  an  affection  long  believed 
to  be  sui  generis  and  to  exhibit  no  lesions  other  than  hemorrhages 
into  the  skin,  mucosae  and  often  in  the  viscera ;  in  other  words,  an  idio- 
pathic acute  or  chronic  hemorrhagic  diathesis  or  acquired  hemophilia. 
In  recent  times  good  authorities  have  insisted  that  the  condition  is 
only  an  intensive  form  of  purpura  simplex,  while  others  appear  to  be- 
lieve that  there  is  no  form  of  purpura  which  may  not  develop  into  the 
affection  in  question,  and  the  latter  may  appear  as  an  equivalent  of 
other  clinical  forms  of  purpura. 

In  some  cases  a  constitutional  reaction  of  malaise,  fever,  rhemiia- 
toid  pains,  gastro-enteric  disturbances,  etc.,  precedes  the  hemor- 
rhages, but  the  more  marked  are  these  the  more  certain  it  seems  that 
the  disease  in  the  special  case  is  essentially  one  of  the  ordinary  erup- 
tive forms  of  purpura.  Prodromes  do  not  seem  essential  to  the  de- 
velopment of  the  disease  and  the  earliest  sjTnptoms  may  be  directly 
dependent  upon  the  loss  of  blood.  The  eruption  appears  on  the 
trunk  and  limbs  and  at  times  upon  the  face,  which  latter  location  is 
regarded  by  some  as  pathognomonic  of  purpura  hemorrhagica,  as  is 
also  the  occurrence  of  hemorrhages  in  the  visible  mucosa?.  A  fact  of 
importance  in  purpura  hemorrhagica  which  may  assist  to  some  extent 
in  differentiating  it  from  minor  forms  is  the  semitraumatic  character 
of  the  lesions. 

The  eruption  may  comprise  every  tj^pe  of  hemorrhagic  cutaneous 
lesions  from  petechias  to  ecchymomata.  The  typical  lesion  is  probably 
a  large,  flat  extravasation  or  ecchymosis. 

A  patient  with  purpura  hemorrhagica  may  present  sj-mptoms  as- 
sociated with  the  exciting  causes  Avhen  these  are  markedly  in  evi- 
dence, and  also  others  due  to  loss  of  blood,  such  as  pallor  and  prostra- 
tion. The  disease  may  run  a  brief  and  benign  course,  recovery  ensu- 
ing within  a  fortnight,  or  a  sort  of  status  may  be  established  in 
which  hemorrhages  recur  and  the  condition  may  then  be  termed 


chronic  or  at  least  subacute.  The  very  acufe,  fatal  cases  in  wliich 
death  occurs  from  internal  hemorrhages  have  sometimes  begun  as 
relatively  mild  purpura. 

Etiology 

The  chief  point  of  interest  in  this  connection  is  the  nature  of  the 
factors  which  cause  this  severe  degree  of  purpura.  The  latter  has 
often  been  noted  in  a  relatively  pure  form  in  syphilis,  tuberculosis, 
nephritis,  influenza,  etc.,  differing  essentially  from  the  hemorrhages 
which  depend  directly  on  the  exanthemas  of  variola,  scarlatina,  etc. 
Of  vital  significance  especially  in  cumulative  incidence  is  the  possi- 
bility of  a  dietetic  factor — insufficient  nutriment  with  especial  refer- 
ence to  potash. 

Cases  of  so-called  "land  scurvy"  occurring  in  pseudo  epidemics 
are  still  reported  from  time  to  time,  and  usually  recover  as  soon  as 
the  diet  is  regulated. 

The  pathology  is  of  the  simplest,  yet  quite  obscure  in  essence. 
The  blood-vessels  and  blood  seem  both  at  fault.  The  former  permit 
diapedesis  and  also  readily  rupture.  The  blood  which  escapes  shows 
delayed  coagulation.  The  absorption  of  the  extravasated  blood 
occurs  more  slowly  than  in  traumatic  cases. 

Diagnosis 

The  implication  of  the  mucosae  and  face,  as  well  as  evidences  of 
internal  hemorrhage  will  serve  to  differentiate  purpura  hemorrhagica 
from  the  more  common  and  comparatively  benign  forms  of  purpura. 

Treatment 

The  general  management  consists  essentially  in  the  use  of  hemo- 
static remedies,  as  rest  in  bed  with  foot  of  same  elevated,  cold  appli- 
cations and  the  internal  administration  of  ergot  and  adrenalin. 
Roller  bandages  on  ihe  legs  may  prevent  further  extravasations.  If 
several  cases  develop  in  a  small  community  or  house,  the  diet  should 
be  carefully  considered  as  to  the  content  of  the  food  in  potash.  For 
the  debility  following  an  attack  the  patient  should  be  put  on  a  gener- 
ous diet  of  meat  and  fresh  vegetables,  with  wine.  Iron,  quinine,  and 
strychnine  in  suitable  doses  wull  also  help  to  restore  the  saline  ingre- 
dients of  the  blood.  Recently  subcutaneous  injections  of  human  blood 
serum  have  been  employed  with  good  results. 

Fig.  6.     Model  in  Vienna  Clinic   {Henning).     Many  intra-  and  sub- 
cutaneous hemorrhages.     Skin  shows  icteric  purpuric  spots. 

Fig.  7.     Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

10 


Plate  5. 


Fig.  9.  Herpes  progenitalis. 


Fig.  10.  Herpes  labialis. 


Herpes  Progenitalis 

Synonyms :    Herpes  preputialis ;  Herpes  genitalis 

Plate  4,  Fig.  8 ;  and  Plate  5,  Fig.  9 

The  above  affection  possesses  an  unusual  degree  of  interest  be- 
cause its  consideration  belongs  alike  to  the  dermatologist  and  genito- 
urinary surgeon.  It  may  follow  coitus  (as  a  result  of  mechanical 
irritation)  and  it  frequently  serves  as  a  port  of  entry  for  the  virus  of 
syphilis.  It  is  also  prone  to  develop  in  male  subjects  who  have  had 
gonorrhea,  apparently  as  the  result  of  irritating  pathological  condi- 
tions in  the  urethra,  vesicles,  or  prostate.  Herpes  progenitalis  is  emi- 
nently a  relapsing  affection.  One  attack  may  be  succeeded  almost 
immediately  by  another. 

In  the  male  the  little  clusters  of  vesicles  appear  either  on  the  inner 
aspect  of  the  prepuce  and  the  glans,  or  on  the  integument  of  the  penis. 
In  the  latter  case  a  typical  cluster  of  vesicles  is  evident  as  in  Fig.  8. 
These  behave  exactly  like  herpes  on  the  face  and  the  nature  of  the 
group  of  shiny  vesicles  is  manifest.  On  a  patient  with  no  prepuce, 
or  only  a  short  one,  the  mucosa  resembles  skin  and  the  vesicles  behave 
in  the  same  manner,  but  in  subjects  with  long  foreskins  the  vesicles 
occurring  on  the  glans  are  quickly  ruptured  and  the  clinical  appear- 
ance is  more  that  of  a  balanitis.  As  a  rule  it  is  not  easy  to  recognize 
the  site  of  the  vesicles  in  these  cases,  owing  to  the  edema  and  retained 
secretion  that  is  often  present. 

We  know  comparatively  little  about  genital  herpes  in  women  and 
authorities  differ  as  to  its  frequency.  The  labia  minora  and  clitoris 
are  the  parts  most  frequently  affected  although  the  eruption  often 
occurs  on  the  labia  majora  and  adjacent  integument,  as  sho^\^l  in 
Fig.  9.  In  certain  cases  the  vesicles  enlarge  to  a  considerable  size  and 
show  a  yellowish  floor  suggestive  of  a  chancroid.  These  enlarged 
vesicles  may  also  coalesce,  so  that  a  large  eroded  surface  results. 
There  is  an  offensive  discharge  and  the  itching  and  burning  is  often 

11 


intense.    The  inguinal  glands  are  frequently  enlarged  and  v/aUiing 
becomes  difficult. 

Diagnosis 

This  should  not  be  difficult  in  an  uncomplicated  case,  but  when  the 
vesicles  have  been  ruptured  and  suppuration  has  taken  place  it  is  not 
always  easy  to  exclude  a  chancroid.  The  latter,  however,  will  gener- 
ally show  deeper  ulceration  and  a  fouler  base.  Time  and  treatment 
will  also  help  to  clear  the  question.  An  attack  of  herpes  is  usually 
cured  in  a  few  days  by  the  use  of  mild  antiseptic  applications,  whereas 
a  chancroid  under  the  same  treatment  would  increase  in  size.  Auto- 
inoculation  of  a  chancroid  is  seldom  justified,  but  pus  may  be  scraped 
from  the  border  of  the  ulcer,  fixed  and  stained,  and  in  the  case  of  a 
chancroid  the  microscope  will  show  the  characteristic  bacillus  of 
Ducrey. 

Primary  syphilis  should  be  readily  excluded  by  the  clinical  history, 
the  absence  of  induration,  and  by  a  negative  laboratory  report  as  to 
the  presence  of  the  spirocheta  pallida. 

A  simple  balanitis  often  resembles  the  condition  seen  in  herpes 
of  the  prepuce  after  the  vesicles  have  ruptured,  but  in  the  former 
affection  there  is  no  history  of  the  presence  of  previous  vesicles.  A 
diabetic  balanitis  is  easily  excluded  by  examination  of  the  urine  for 
glucose. 

Local  Treatment 

The  treatment  of  the  lesions  of  herpes  progenitalis  is  usually  as 
efficacious  as  it  is  simple.  Few  cases  fail  to  respond  to  cleanliness  and 
mild  antiseptic  dusting  powders.  In  male  patients  the  prepuce  should 
be  retracted  and  the  glans  and  contiguous  mucous  membrane  cleaned 
with  a  weak  boric  acid  solution  and  an  application  of  aristol  made 
over  the  vesicles.  If  there  is  infection  or  ruptured  vesicles,  it  is  well 
to  use  a  50%  solution  of  hydrogen  peroxide  before  applying  the  aris- 
tol. Other  powders  that  may  prove  efficient  are  acetanilid,  calomel, 
subnitrate  of  bismuth,  and  oxide  of  zinc.  A  redundant  prepuce  should 
be  separated  from  the  glans  by  a  strip  of  gauze  or  pledget  of  cotton. 
If  there  be  much  edema  the  patient  should  be  instructed  to  hold  the 
penis  in  a  cup  of  warm  water  for  several  minutes,  two  or  three  times  a 
day.  To  hasten  the  healing  of  ruptured  vesicles,  the  use  of  an  astrin- 
gent wash  is  often  beneficial.  Powdered  alum,  gr.  xx  to  gr.  xxx  to  the 
ounce  of  water,  makes  a  very  good  one.  For  superficial  ulcerations 
the  silver  nitrate  stick  may  be  used. 

12 


Prophylaxis 

Under  this  caption  may  be  considered  treatment  designed  to  pre- 
vent the  reguhir  or  irregular  recurrence  of  the  affection. 

First  of  all,  the  general  health,  which  in  these  patients  is  nearly 
always  lowered,  should  be  improved.  Tonics  containing  iron,  quinia, 
and  strychnia  are  often  beneficial  and  in  certain  chronic  cases  arsenic 
has  proved  of  distinct  value.  Errors  of  diet  should  be  corrected  and 
careful  attention  given  to  gastric  and  intestinal  derangements.  Alco- 
holic and  fermentative  liquors,  as  well  as  tobacco,  generally  act 
prejudicially. 

Patients  should  be  thoroughly  instructed  in  sexual  hygiene  as  the 
congestion  of  the  genital  organs  following  prolonged  sexual  excite- 
ment is  often  a  prominent  factor  in  the  causation  of  this  affection. 
"Wliile  it  is  advisable  to  have  a  long  tight  foreskin  removed  it  must  be 
borne  in  mind  that  circumcision  does  not  always  prevent  recurrent 
attacks.  Some  of  the  most  rebellious  cases  that  I  have  had  under 
observation  occurred  in  individuals  who  had  been  circumcised  in 
early  infancy.  In  some  cases  benefit  follows  the  regular  passage  of 
cold  sounds  and  instillations  of  argyrol.  One  phase  of  the  prophylac- 
tic treatment  that  is  rarely  spoken  of  in  text-books  is  the  treatment  of 
pathological  conditions  of  the  seminal  vesicles.  A  number  of  my 
cases  apparently  depended  upon  a  chronic  catarrhal  inflammation  of 
the  vesicles  and  treatment  directed  to  the  vesiculitis  caused  a  cessa- 
tion of  attacks  after  numerous  other  forms  of  treatment  had  failed. 


Fig.  8.     Model  in  St.  Louis  Hospital  in  Paris,  No.  1923  (Baretta). 

P'ournicr's  case. 

Fig.  9.     Model  in  Dermatological  Clinic  in  Freiburg  {Vogelbacher). 

13 


Herpes  Simplex 

Synonyms:   Herpes  facialis,  Herpes  labialis 

Plate  5,  Fig.  10 

Strictly  speaking,  genital  herpes  belongs  in  this  category,  but  for 
practical  reasons  it  is  better  to  regard  it  as  a  distinct  affection. 
Herpes  simplex  may  occur  in  almost  any  locality  as  the  result  of  a 
possible  nerve  injury  or  irritation.  In  practice,  however,  the  affec- 
tion is  limited  to  the  face — chiefly  about  the  lips  and  outlying  skin. 
Occurring  at  the  junction  of  the  skin  and  mucous  membrane  at  the 
mouth  or  nostril  it  is  the  familiar  "cold  sore,"  which  accompanies 
an  acute  coryza.  These  forms  are  extremely  common,  and  are  limited, 
as  a  rule,  to  a  single  small  cluster  of  vesicles.  Herpes  facialis,  so 
called,  is  a  cutaneous  eruption,  not  necessarily  limited  to  one  area, 
but  able  to  involve  a  large  portion  of  the  face.  It  is  usually  associated 
with  acute  affections  like  pneumonia  and  influenza,  the  "fever  blis- 
ters" of  the  laity,  and  is  not,  as  has  sometimes  been  thought,  any 
criterion  of  the  severity  of  the  disease.  The  lesions  are  composed 
of  clusters  of  vesicles,  the  numbers  of  both  vesicles  and  clusters 
varying.  The  clusters  are  usually  grouped  together,  forming  large 
patches.  The  vesicles  appear  on  a  slightly  hyperemic  base  and  are 
nearly  always  attended  with  pricking  sensations  and  soreness.  They 
are  naturally  minute,  but  may  attain  considerable  size  as  if  from 
coalescence  (hence  the  popular  word  blister).  The  liquid  contents 
are  absorbed  or  become  desiccated,  and  a  discharge  never  occurs. 
The  disease  runs  a  definite  course,  lasting  a  week  or  ten  days,  at 
the  close  of  which  period  a  scab  is  detached.  There  is  considerable 
tendency  to  recurrence  in  the  same  area ;  in  fact,  in  the  minor  forms 
one  attack  appears  to  predispose  to  others.  The  peculiar  nervous 
sensations,  the  character  of  the  little  vesicles  and  the  occasional 
association  of  slight  irritation — for  example,  the  irritation  of  the 
nostril  and  upper  lip  at  the  outset  of  a  cold — show  plainly  a  nerve 
element  in  the  make  up  of  the  affection — reflex  or  ganglionic. 

14 


Diagnosis 

Extensive  facial  herpes  with  much  crusting  may  have  to  be  dis- 
tinguished from  other  facial  eruptions — eczema  and  impetigo — but 
this  should  not  be  difficult. 

Treatment 

The  frequent  application  of  spirits  of  camphor  to  the  lesions  will 
relieve  the  burning  and  hasten  their  disappearance.  AVhen  the  crust- 
ing stage  is  reached  ointments  are  indicated.  The  following  is  a  good 
one,  particularly  for  herpes  labialis: 

IJ  Tinct.  camphor IlKvii 

Pulv.  calamine  prep gr.  v 

Zinci  oxidi gr.  vii 

Aquae  rosae 3ii 

M.  et  ft.  ungt. 

In  the  troublesome,  periodic  form  Norman  Walker  recommends 
the  painting  of  the  affected  area  with  argent,  nitralis  (gr.  xx)  spr. 
a'ther.  nitrosi  (gi).  This  he  believes  will  often  increase  the  intervals 
between  attacks,  and  will  in  time  bring  about  a  cure. 


Fig.  10.     Model  in  Dermatological  Clinic  in  Freiburg  (Vogelbachtr). 

15 


Herpes  Zoster 

Synonyms:    Shingles,  Zona 
Plate  6,  Fig.  11;  and  Plate  7,  Fig.  12 

Herpes  zoster  differs  from  all  other  acute  affections  of  the  skin  in 
that  it  is  a  secondary  manifestation,  due  to  an  acute  inflammation  of 
the  nerve  fibers  which  are  distributed  in  the  affected  area.  There  are 
few  cutaneous  affections  of  which  the  mechanism  is  so  simple,  even  if 
the  ultimate  causal  factors  are  obscure.  The  disease  has  points  in 
common  with  herpes  simplex,  in  which  the  terminal  nerve-filaments 
are  doubtless  involved,  but  not  the  main  nerve-trunks.  In  both  herpes 
simplex  and  progenitalis,  clusters  of  vesicles  arise  rapidly  on  a  hyper- 
emic  base  with  unpleasant  tingling  and  pricking  sensations;  but  in 
zoster  the  pain  may  be  extreme — neuralgiform — and  is  associated 
often  with  intense  hyperesthesia.  In  some  cases  the  pain  antedates 
the  eruption  by  several  days.  Like  simple  herpes,  zoster  runs  a 
definite  course  and  is  self-limited.  The  eruption  requires  about  two 
days  for  its  evolution,  and  on  an  average  a  week  elapses  before  it 
begins  to  subside.  The  vesicles,  as  in  herpes  simplex,  do  not  rupture 
and  dry  into  scabs.  Unlike  the  former  they  may  leave  permanent 
scars. 

Although  herpes  zoster  is  almost  necessarily  unilateral,  bilateral 
cases  have  occurred.  In  the  great  majority  of  cases  the  affection 
occurs  on  the  trunk  or  region  of  the  eye.  The  areas  that  may  be  in- 
volved vary  greatly  in  extent.  In  zoster  of  the  ear,  an  affection  not 
much  discussed  by  dermatologists,  a  few  vesicles  only  may  suffice  for 
the  expression  of  the  disease.  Conversely  in  zoster  of  a  lower  extrem- 
ity the  area  affected  may  be  very  extensive.  Differences  also  occur 
based  on  the  severity  of  the  case.  Thus  in  a  given  area  there  may  be 
only  a  few  vesicles  localized  at  one  point  or  the  entire  area  may  be 
the  seat  of  clusters. 

Zoster  of  the  face  and  head  seems  more  severe  than  elsewhere, 
because  for  some  reason  acute  trophic  lesions  may  accompany  the 
ordinary  phenomena.  Naturally  in  zoster  involving  the  eyeball  a  few 
vesicles  on  the  cornea  may  result  in  opacities ;  but  there  is  added  a 

16 


Plate  6. 


fig.  11.  Herpes  zoster. 


cortain  pernicious  quality  to  tlie  eruption  by  reason  of  wliicli  tlio  eye- 
ball may  be  destroyed.  Deep  scars  often  remain  on  the  forehead,  due 
perhaps  in  part  to  diminished  resistance  of  the  tissues.  For  the  same 
reason  the  vesicles  may  become  infected,  and  as  a  result  of  thrombo- 
phlebitis fatal  intracranial  mischief  may  be  set  up. 

Zoster  affecting  the  face  may  be  accompanied  by  vesicles  on  the 
mucous  membranes  and  trophic  alterations  in  the  teeth.  Contrary  to 
what  one  would  expect,  the  motor  component  is  almost  negligible  in 
zoster.  Cases  of  paralysis,  some  permanent,  have  been  recorded ;  also 
isolated  cases  of  spasm. 

Eiiologj/ 

It  has  been  conclusively  demonstrated  by  Head  that  the  affection 
is  due  to  a  hemorrhage  or  other  pathological  change  in  a  posterior 
spinal  ganglion  and  that  with  almost  unfailing  regularity  the  location 
of  the  eruption  is  determined  by  the  cutaneous  distribution  of  the 
nerve-fibers  that  i)ass  through  the  affected  ganglion.  In  regard  to  the 
factors  which  determine  the  nerve-lesion,  these  seem  to  be  legion. 
The  most  important  appears  to  be  a  specific  conununicable  virus 
which  often  causes  small  epidermics.  In  this  type  of  zoster  we  see 
malaise,  fever  and  other  phenomena  observed  in  acute  infectious 
diseases.  Generally  speaking,  any  circulating  poison  in  the  blood, 
any  form  of  reflex  irritation  and  traumatic  influences  (as  in  herpes 
simplex)  may  be  able  to  produce  zoster;  whence  some  would  distin- 
guish between  true  zoster  and  zosteroid  eruptions.  "Well  recognized 
indi\'idual  causes  are  arsenic  (it  frequently  follows  injections  of 
salvarsan),  carbon  monoxide,  and  malaria.  It  is  not  uncommon  in 
tuberculosis.  The  evidence  in  support  of  reflex  causation  seems 
weakest. 

Diagnosis 

The  earliest  vesicles  of  zoster,  associated  as  they  usually  are  ^^'ith 
pricking  sensations,  are  sometimes  mistaken  for  local  effects  of  bites 
or  other  traumatism.  Typical  herpes  zoster  should  hardly  be  con- 
founded with  any  other  eruption  because  of  its  unilateral  distribution 
and  peculiar  subjective  sensations.  Zoster  on  the  face  may  of  course 
be  confused  with  herpes  facialis  and  conditions  resembling  it.  In  se- 
vere cases,  however,  it  would  be  more  likely  to  suggest  erysipelas. 
The  latter,  however,  has  constitutional  s>nni)toms,  is  bilateral,  infil- 
trated, and  has  the  characteristic  sharply  defined  margin.  Zoster 
may  run  an  abortive  course  and  these  cases  are  sometimes  misleading. 

17 


Prognosis 

Certain  features  of  zoster  may  bring  up  the  question  of  prognosis, 
although  generally  speaking  a  mild  self-limited  affection  can  have  but 
one  prognosis.  If  the  affection  occurs  in  connection  with  a  neuritis 
or  neuralgia  the  pain  may  persist  and  even  increase.  The  pitting 
about  the  face  and  head  may  be  deep,  and  the  practitioner  may  well 
be  on  his  guard  in  calling  the  affection  a  trifling  one.  This  obtains 
even  more  strongly  in  zoster  ophthalmicus,  in  which  the  cornea  may 
be  rendered  opaque  with  resulting  blindness.  The  fact  must  not  be 
lost  sight  of  that  zoster  has  been  known  to  end  in  gangrene. 

Treatment 

Some  authors,  who  evidently  confound  the  predisposition  with  the 
actual  disease,  advise  the  general  regimen  for  neuralgia,  such  as  nerve 
tonics  (arsenic,  iron,  quinia),  coupled  with  change  of  climate  neces- 
sary for  all  gouty  and  malarial  subjects.  Since  zoster  seldom  recurs, 
it  is  difficult  to  understand  how  this  regimen  could  influence  an  acute 
self-limited  affection.  We  can  only  interpret  this  management  as 
something  directed  to  the  underlying  condition  of  which  the  disease 
is  a  transient  expression. 

The  pain  may  be  the  chief  cause  of  the  patient's  visit,  and  as  pain 
is  almost  always  in  evidence  the  practitioner  should  be  prepared  to 
mitigate  it.  Among  anodynes  a  hypodermic  of  morphine  close  to  the 
area  involved  is  usually  effective,  but  satisfactory  results  may  often 
be  attained  by  the  use  of  acetanilid  or  phenacetin.  A  remedy  upheld 
for  many  years  is  galvanism  along  the  affected  nerve  to  the  extent  of 
five  milliamperes  with  a  ten-minute  exposure.  Measures  well  spoken 
of  are  blisters  over  the  part  of  the  spine  at  the  point  of  exit  of  the 
sensory  nerve,  and  mild  freezing,  with  ethyl  chloride  or  dry  cupping, 
at  the  same  point.  Of  the  numerous  local  applications  recommended, 
not  much  is  to  be  expected ;  they  may  all  be  summed  up  under  pro- 
tection and  immobilization,  which  may  be  effected  by  dusting  the  area 
heavily  with  talcum  powder  and  then  applying  a  tight  bandage,  the 
inside  of  which  is  also  thickly  coated  with  the  same  powder.  Such  a 
dressing,  which  need  be  changed  but  once,  will  usually  suffice  for  the 
local  treatment  of  an  ordinary  case.  Care  should  be  taken  not  to  rup- 
ture the  vesicles  so  as  to  prevent  the  possibility  of  infection  with  sub- 
sequent scars. 

Fig.  11.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 
Fig.  12.    Model  in  Lesser's  Clinic  in  Berlin  (Kolbow). 

18 


P  ate  7. 


o 

c 

c 


o 


CN 


be 


Pompholyx 

Synonyms:    Dysidrosis,  Clieiro-pompholyx 

Plate  7,  Fig.  13 

This  is  a  purely  topical  affection,  limited  to  the  extremities  and 
chiefly  the  palmar  and  plantar  aspects.  The  fingers  are  commonly  in- 
volved, and  the  eruption  is  usually  sjTnmetrical.  The  lesions  consist 
of  vesicles  and  bullse,  the  latter  resulting  from  distention  and  coales- 
cence of  the  former.  These  lesions  tend  to  appear  in  clusters,  and  are 
quite  deeply  seated,  so  that  they  have  been  compared  to  boiled  sago 
grains.  If  not  too  crowded,  there  may  be  no  coalescence  to  form 
bulla;,  and  the  enlarged  vesicles  may  disappear  from  absorption  of 
their  contents.  If  absorption  does  not  occur,  the  contents  become 
cloudy  and  at  times  purulent;  when  coalescence  takes  place  actual 
bullap  may  form  or  the  entire  epidermis  may  exfoliate.  The  eruptions 
appear  in  crops  or  more  or  less  continuously,  and  after  a  variable 
interval,  perhaps  of  several  months,  spontaneous  recovery  occurs. 
The  affected  parts  usually  show  poor  circulation  and  excessive  per- 
spiration, and  the  eruption  is  usually  attended  A\nth  burning  and 
itching.  There  is  more  or  less  absence  of  type,  so  that  cases  show 
considerable  individuality.  There  is  some  reason  to  believe  that 
abortive  forms,  limited  to  a  few  transitory  vesicles,  may  not  be  as 
rare  as  the  disease  itself  is  believed  to  be. 

Etiology 

The  earliest  observers  had  no  doubt  that  the  affection  represented 
a  disorder  of  the  sweat-glands  and  that  the  vesicles  were  simply  re- 
tained perspiration— whence  the  name  dysidrosis.  This  error— for 
an  error  it  was — was  most  natural,  for  the  affection  is  limited  to 
areas  where  the  sweat-glands  are  both  large  and  numerous,  and  the 
patients,  as  a  rule,  showed  habitual  hyperidrosis  of  the  extremities. 
That  the  lesions  are  not  mere  retention  cysts  containing  sweat  was 
soon  made  evident.  This  fluid  is  pure  blood  serum,  and  pomphoh-x, 
while  not  strongly  resembling  a  weeping  eczema,  is  more  closely 

19 


allied  to  it  than  to  any  other  known  affection.  Little  is  known  of 
the  cause;  but  the  disease  is  common  in  women  during  the  repro- 
ductive cycle,  and  nervous  and  psychic  influences  are  often  in  evidence 
in  relation  to  an  attack. 

Diagnosis 

Since  pompholyx  is  a  local  affection  limited  to  certain  areas,  diag- 
nosis should  not  be  difficult.  The  indirect  method  of  exclusion  may  be 
necessary  in  certain  atypical  cases.  The  only  affections  which  might 
cause  confusion  are  acute  vesicular  eczema  and  certain  forms  of 
localized  dermatitis  venenata,  notably  ivy  poisoning.  Some  confusion 
has  arisen  in  past  years  between  pompholyx  and  pemphigus ;  this  is 
due  to  the  common  bullous  character  and  similarity  in  sound  of  the 
names — also  perhaps  to  the  fact  that  pemphigus  is  sometimes  located 
on  the  extremities.  The  two  conditions,  however,  should  never 
occasion  any  confusion  in  practice. 

Prognosis 

A  case  of  dysidrosis  is  often  tedious,  but  the  individual  attack  will 
undergo  involution  sooner  or  later.  The  unfavorable  element  is  con- 
nected with  recurrence,  which  is  likely  to  occur  under  precisely  those 
conditions  which  cannot  be  foreseen  or  prevented. 

Treatment 

The  best  results,  both  in  arresting  an  attack  and  preventing  a  re- 
currence, will  come  about  through  internal  medication.  Arsenic  fre- 
quently appears  to  have  considerable  control  over  the  eruption,  and 
arrests  its  development.  Other  drugs  of  value  are  iron,  quinia, 
strychnia,  and  the  hypophosphites.  The  external  applications  should 
consist  of  soothing  and  drying  applications.  Relief  is  generally 
afforded  by  Lassar's  paste  or  by  Hebra's  diachylon  ointment.  Here 
is  the  formula  of  the  latter: 

T^  Olei  oli'varum  optimi    ^v 

Plumbi  oxidi   5i 

Olei  lavanduliB 9  ii 

M.  et  ft.  ungt. 

Lotions  of  calamine  and  zinc  and  of  lead  and  opium  are  also  useful. 
Fig.  13.    Model  in  Neisser's  Clinic  in  Breslau  (Kroener). 

20 


Plate  8. 


Fig.  14.   Impetigo  contagiosa. 


Impetigo  Contagiosa 

Plate  8,  Fig.  14 

This  affection,  highly  contagious,  often  disfiguring  and  well  cal- 
culated to  cause  alarm,  is,  in  reality,  a  very  benign,  superficial  malady, 
which  would  demand  but  little  attention  were  it  not  so  liable  to  con- 
fusion with  other  and  much  more  serious  dermatoses.  It  yields 
to  the  simplest  treatment,  and  even  if  left  to  itself  would  recover 
within  a  comparatively  short  time,  despite  the  fact  that  it  is  auto- 
inoculable,  and  that  many  of  its  lesions  doubtless  originate  in  this 
manner.  The  name  impetigo  is  a  decided  misnomer,  as  tliis  implies 
that  the  affection  is  essentially  pustular.  As  a  matter  of  fact  the 
essential  lesions  are  vesicles  and  bullfc,  the  contents  of  which  quickly 
become  turbid  from  leucocytes ;  so  that  when  rupture  occurs  and  the 
fluid  evaporates,  thin  crusts  are  formed  which  adhere  rather  closely 
to  the  skin.  These,  when  detached,  show  a  slightly  reddened  integu- 
ment, which  exhibits  a  slight  tendency  to  ooze  at  the  sites  of  the 
original  vesicles  or  bulls'.  While  this  affection  may  occur  in  a 
typical  form,  and  spontaneously,  we  also  see  cases  in  which  it 
apparently  complicates  some  other  affection  in  which  scratching  and 
abrasions  are  features.  It  is  not  uncommonly  determined  by  vacci- 
nation; and  in  pediculi  capitis  in  children  it  is  so  closely  associated 
by  authors  Avith  the  vesiculo-pustular  outbreaks  on  the  neck,  etc., 
that  some  have  gone  so  far  as  to  state  that  pediculosis  is  one  of  the 
most  common  causes  of  impetigo  contagiosa.  In  ordinary  cases  of  the 
latter  they  would  always  look  for  pediculi.  A  point  not  sufTicioiitly 
discussed  is  the  relation  of  impetigo  to  scabies.  Some  claim  that  the 
frequent  location  of  the  affection  about  the  lips  and  nostrils  may 
have  some  bearing  on  the  secondary  infection  of  a  herpes  simplex.  It 
will  thus  be  seen  that  impetigo  may  behave  as  a  primary  or  secondary 
affection. 

It  is  commonly  stated  that  impetigo  contagiosa  is  due  to  ordinary 
pus  exciters — staphylo — and  especially  streptococci.  It  is  interesting 
to  note  that  the  secretions  of  tliese  lesions  are  being  continually  in- 

21 


oculated,  but  that  local  and  general  infection  never  appear  to  develop 
even  in  abortive  forms.  In  some  cases,  however,  where  the  out- 
break is  extensive,  we  note  a  mild  general  reaction  with  fever  and 
adenopathy. 

Impetigo  contagiosa  is  very  largely  an  affection  of  childhood,  at- 
tacking chiefly  the  dirty  and  unkempt,  in  whom  it  pursues  a  fairly 
typical  course.  But  it  is  of  much  greater  significance  when  it  attacks 
adults,  especially  those  who  are  of  neat  habits.  Here  its  behavior 
is  often  highly  atypical,  and  the  sudden  appearance  of  lesions  on  the 
face  and  throat  usually  leads  the  patient  to  believe  that  barber's  itch 
or  syphilis,  or  some  other  more  or  less  reprehensible  malady,  has  been 
contracted.  Petty  epidemics  sometimes  arise  in  coimection  with 
public  swimming  baths. 

The  sole  lesion,  in  the  vast  majority  of  cases,  is  the  flattened 
crust,  which  may  be  gray,  yellow,  or  broA\Ti.  This  occurs  by  pref- 
erence on  the  exposed  surfaces — face,  neck,  hands,  wrists,  etc.,  and, 
in  children  who  go  barefoot,  on  the  feet  and  legs.  But  no  one 
should  rest  satisfied  with  this  picture,  for  lesions  may  not  only 
appear  in  almost  any  locality,  but  may  exhibit  a  bizarre  behavior. 
Thus  Scliamherg  illustrates  a  case  in  which  the  lesions  occupied  the 
groins  and  axillae,  and  exhibited  a  cireinate,  serpiginous  progression. 
If  we  bear  in  mind  that  the  affection  can  be  grafted  upon  other 
conditions  we  must  be  prepared  for  much  variety  and  ambiguity  in 
expression  in  selected  cases. 

Etiology 

In  the  absence  of  any  specific  cause  Bocl:hart's  view  that  it  may 
be  caused  by  a  variety  of  germs  which  exert  a  very  superficial  action 
may  be  accepted  for  the  present.  The  lesions,  as  becomes  vesicles 
and  bullae,  occupy  the  space  between  the  horny  and  mucous  layers, 
which  accounts  for  the  fact  that  the  latter,  the  corium,  lymphatics, 
etc.,  escape  all  serious  implication. 

Diagnosis 

We  have  to  exclude  eczema,  and  as  impetigo  may  be  grafted  upon 
the  latter  the  differentiation  is  not  always  easy.  Results  of  treatment 
in  eczema,  as  in  other  maladies,  must  decide,  for  impetigo  yields  very 
promptly  to  treatment.  There  should  be  no  confusion  with  sycosis 
of  either  type,  because  there  is  no  involvement  of  the  hair-follicles. 
Exclusion  of  syphilis  is  sometimes  difficult,  but  as  good  a  diagnostic 
procedure  as  any  is  the  simple  detachment  of  the  crusts  which  demon- 

22 


strates  the  entirely  superficial  character  of  the  lesions  of  impetigo 
contagiosa. 

Treatment 

The  affection  is  perhaps  more  easily  cured  than  any  other  of 
its  class.  Hence  tliere  is  no  need  to  use  applications  in  any  notable 
concentration.  If  there  should  be  any  dilhculty  in  detaching  the 
crusts  they  may  be  softened  with  borated  vaseline.  The  exposed 
surface  sliould  tlion  be  cleansed  -with  an  antiseptic  solution,  and  if 
the  eruption  is  general  an  antiseptic  bath  may  be  given.  The  best 
application  for  the  lesions  is  an  ointment  of  white  precipitate.  The 
usual  strength  of  thirty  grains  to  the  ounce  is  unnecessarily  high,  and 
wliile  comparatively  harmless,  is  less  effective  than  a  two  per  cent, 
ointnient.    An  efficient  formula  is : 

IJ  Hydrarg.  ammon gr.  x 

Zinci  oxidi 9  i 

Ungt.  aq.  rosse 51 

M.  et  ft.  ungt. 


Fig.  14.     Model  in  Dcrmatological  Clinic  in  Freiburg  (Vogclbacher). 

23 


Hydroa  Vacciniforme 

Synonym:    Hydroa  aestivale 

Plate  9,  Fig.  15 

This  is  an  affection  of  cliildliood  and  adolescence,  hence  in  part  de- 
velopmental, which  tends  to  appear  in  successive  summers.  It  may  be 
papular,  but  is  usually  vesicular  and,  like  vaccine  vesicles,  leaves  pits. 

It  is  very  largely  limited  to  males.  Since  it  occurs  by  preference 
on  exposed  surfaces  it  presents  almost  the  same  causal  factors  as 
freckles.  It  is,  moreover,  a  familial  affection  in  certain  cases.  The 
lesions  come  out  somewhat  like  a  rash,  with  some  general  disorder  and 
local  sensory  disturbance — burning,  or  more  rarely  itching. 

In  a  well-marked  case  the  nose,  cheeks  and  ears  are  first  the  seat 
of  a  diffuse  or  circumscribed  redness.  As  a  rule,  small  vesicles,  the 
largest  pea-sized,  appear  on  this  basis.  The  considerable  size  of  some 
of  the  vesicles  is  responsible  for  the  term  hydroa.  Coalescence  is 
rare,  but  blebs  have  sometimes  formed.  The  contents  of  the  vesicles 
are  at  first  clear,  then  turbid.  The  majority  of  them  undergo  distinct 
umbilication,  after  which  crusts  form  and  come  away,  leaving  small 
scars. 

The  vesicles  may  appear  in  several  successive  crops  during  the 
summer,  at  intervals  of  several  weeks ;  or,  more  commonly,  there  is  a 
more  or  less  continuous  evolution  of  them.  This,  with  the  annual  re- 
currence, will  tend  in  the  worst  cases  to  very  extensive  pitting  of  the 
nose  and  other  localities.  There  are  numerous  atypical  forms.  The 
affection  may  be  abortive  and  may  not  reach  the  vesicular  stage ;  or  it 
may  appear  in  cool  weather  and  in  adults.  In  some  cases  there  may 
be  considerable  scattered  eruption  on  the  covered  regions. 

Etiology 

Aside  from  the  predisposition  the  sole  causal  factor  appears  to  be 
the  summer  sun,  and  wind.  The  pathologic  process  is  an  inflamma- 
tion of  the  papillary  layer  of  the  corium. 

24! 


Plate  9. 


Fig.  15.  Hydroa  vacciniformis, 


Diagnosis 

Several  somewhat  sinxilar  conditions  liave  been  described,  and  it  is 
a  question  whethei-  or  not  they  are  simply  atypical  forms  of  hydroa 
vacciniforme.  Unna's  hydroa  puerorum  shows  no  tendency  to  a  sea- 
sonal incidence  and  does  not  lead  to  scarring.  Summer  prurigo  is  a 
papular  itchy  eruption,  diffused  over  the  integument. 

Treatment 

The  face  should  be  protected  from  the  chemical  rays  of  the  sun, 
and  most  authorities  reconmiend  the  wearing  of  orange  or  red  or 
dark-colored  veils.  Theoretically,  this  may  be  good  prophylactic 
treatment,  but  it  must  be  remembered  that  our  patient  is  a  small  boy 
at  play  with  his  fellows  and,  well,  a  small  boy  is  a  small  boy  the  world 
over.  The  application  of  a  thick  lotion  containing  calamine,  mag- 
nesia, and  zinc  would  be  more  practical  and  quite  as  effective.  Nor- 
man Walker  suggests  that  in  mild  cases  it  is  often  best  to  explain  the 
nature  of  the  disease  to  the  parents,  and  tell  them  not  to  worry  too 
much  about  it. 


Fig.  15.     Model  in  Dermatological  Clinic  in  Freiburg  (Vogelbacher). 

25 


Pemphigus  Vulgaris 

Plate  10,  Fig.  16 

Pemphigus  is  a  term  that  has  been  applied  to  a  variety  of  bullous 
affections,  certain  of  which  have  but  little  in  common  beyond  the 
presence  of  the  bullae  themselves.  Since  any  intense  inflammation  of 
the  skin,  however  produced,  may  give  rise  to  bullae,  it  is  necessary 
first  of  all  to  distinguish  between  pemphigus  proper  and  the  pemphi- 
goid eruptions,  especially  such  as  dermatitis  herpetiformis,  urticaria 
bullosa,  etc.  It  must  not  be  forgotten  that  in  nearly  all  vesicular  af- 
fections bullae  may  result  from  coalescence,  sometimes  as  a  rule,  some- 
times only  exceptionally.  The  presence  of  bullae  under  such  circum- 
stances may  be  obscured  by  their  rapid  rupture,  or  by  the  drying  of 
the  turbid  contents  into  crusts  or  scabs.  Thus  some  writers  affect  to 
believe  that  impetigo  contagiosa  measures  up  to  the  standards  of  true 
pemphigus.  There  are  also  eruptions  in  which  the  lesions  are  inter- 
mediate in  size  between  vesicles  and  bullae  which  are  termed  hydroa, 
and  some  of  which  appear  to  present  no  essential  differences  from 
pemphigus.  Finally,  the  affection  known  as  pompholyx  has  often 
been  confused  with  pemphigus. 

It  is  therefore  highly  important  to  determine  not  only  whatever 
does  not  belong  to  true  pemphigus,  but  to  give  to  the  latter  all  the 
positive  attributes  possible.  First  of  all  pemphigus  must  be  regarded 
as  a  rare  and  a  chronic  affection.  Its  essential  primary  lesions  are  al- 
ways bullae  at  the  very  outset.  They  must  arise  either  upon  normal 
skin,  or  at  most  on  skin  which  is  slightly  reddened.  They  have  no 
limited  areas  of  distribution,  but  may  appear  on  almost  any  portion 
of  the  integument,  and  save  in  the  universal  forms,  independently  of 
any  local  or  traimaatic  factors.  The  fact  that  the  mucosae  suffer  with 
the  skin  in  severe  cases  also  shows  plainly  the  endogenous  nature  of 
the  malady.  Several  well-defined  types  of  pemphigus  exist,  but  to 
what  extent  these  represent  separate  affections  or  mere  varieties  or 
degrees  of  intensity  cannot  be  determined. 


Plate  10. 


p;rr     \  f\      Pf»»iit-vhi(Tii<  \_iilnfiiriQ 


Pemphigus  vulgaris  is  appropriately  named,  as  it  is  the  most 
coimnon  type  of  the  alTection.  It  is  a  chronic  affection  only  in  the 
sense  that  new  lesions  continue  to  appear.  They  do  not,  however, 
change  their  type,  for  the  bulla;  in  a  long-standing  case  do  not  differ 
from  those  of  the  first  outbreak.  In  the  main  the  lesions  appear  in 
crops,  with  intervals  of  latencj' ;  but  as  in  all  diseases  which  manifest 
themselves  by  successive  outbreaks,  we  may  at  times  encounter  serial 
or  overlapping  cases  in  which  the  surface  appears  to  be  constantly 
covered  with  bulla>.  In  these  cases  there  is  usually  some  marked  con- 
stitutional involvement  and  the  prognosis  is  grave,  altliough  death 
may  not  be  due  directly  to  the  eruption,  which  may  cause  of  itself 
but  little  general  disturbance.  Even  if  the  single  first  outbreak  is  un- 
usually thick  or  confluent,  the  prognosis  is  much  more  serious  than 
when  it  is  sparse.  The  bulhe  are  therefore  rather  an  index  of  some, 
perhaps  grave,  general  state  than  a  direct  cause  of  death,  which  may 
be  due  to  the  most  varied  causes.  As  will  be  seen  later,  the  two  other 
forms  of  pemphigus  appear  to  be  able  to  destroy  life  directly,  and  it 
is  no  doubt  true  that  pemphigus  vulgaris  may  sometimes  pursue  a 
similar  course.  It  appears  justifiable  to  speak  of  benign  and  ma- 
lignant penipliigus  \mlgaris. 

Under  ordinary  circumstances,  or,  as  we  may  say  in  benign  cases, 
a  crop  of  bullae  requires  one  or  two  days  for  its  evolution  and  one 
or  two  weeks  for  its  involution.  Sooner  or  later  a  new  outbreak  ap- 
pears, followed  by  others,  which  are  less  and  less  pronounced,  until 
after  some  months  the  process  is  arrested. 

Etiology 

Nothing  is  known  of  the  intimate  nature  of  pemphigus  vulgaris, 
and  even  the  conditions  under  which  it  occurs  show  little  uniformity. 
Several  causal  factors  are  vaguely  evident.  One  is  a  neurotic  ele- 
ment, suggesting  that  in  miscellaneous  affections  of  the  central  and 
perhaps  the  peripheral  nervous  system  there  may  be  a  lowered  re- 
sistance of  the  skin  to  noxa;  of  various  kinds.  Another  element  is  the 
frequent  suspicion  of  contamination  from  human  or  animal  disease 
products ;  in  some  cases  the  causation  appears  to  be  septic  infection 
of  the  ordinary  sort.  Autotoxemia,  including  the  intestinal  tj-pe,  is 
a  third  factor  often  recognizable. 

Diagnosis 

Pemphigus  vulgaris  requires  differentiation  only  from  the  other 
types  of  pemphigus  and  from  such  pemphigoid  eruptions  as  eryth- 

27 


ema  naultiforme,  urticaria  bullosa,  and  dermatitis  herpetiformis. 
This  should  not  be  difficult  after  a  given  case  has  been  under  observa- 
tion for  some  time. 

Prognosis 

As  a  rule,  the  greater  the  freedom  from  local  and  general  com- 
plications of  any  sort  and  the  more  scanty  the  eruption,  the  better  the 
outlook,  which  is,  under  other  conditions,  always  serious. 

Treatment 

Arsenic  has  an  unquestionably  specific  action  on  pemphigus  vul- 
garis, but  whether  it  can  save  life  in  the  grave  cases  is  open  to 
doubt.  It  is  often  combined  with  strychnia  and  quinia  and  other 
tonics.  The  patient  should  be  studied  thoroughly  and  be  given  the 
advantage  of  any  improved  hygiene.  Locally,  the  management  is 
practically  that  of  intensive  moist  eczema — the  same  medicated  baths, 
lotions,  etc.  Hehra,  many  years  ago,  treated  pemphigus  with  the  con- 
tinuous bath,  and  this  resource  is  well  calculated  to  make  the  patient 
as  comfortable  as  possible  under  the  circumstances.  The  same  end 
may  be  attained  by  a  system  of  dressings,  as  in  the  case  of  universal 
eczema,  severe  burns,  etc. 


Fig.  16.     Model  in  Dermatological  Clinic  in  Freiburg  (Vogclbacher).     Ma- 
lignant pemphigus  vulgaris.     Death  ensued  within  a  few  weeks. 

38 


Fig.  17.  Pemphigus  foliaceus. 


Plate  11. 


Pemphigus  Foliaceus 

Plate  11,  Fig.  17 

In  this  form  of  pemphigus,  as  in  pemphigus  vulgaris,  new  buUffi 
constantly  appear;  but  since  the  areas  denuded  show  no  tendency 
whatever  to  heal,  the  disease  picture  differs  extremely  from  that  of 
the  ordinary  form.  Pemphigus  foliaceus  may  develop  from  pem- 
phigus vulgaris  or  may  appear  de  novo.  "VNlien  the  bulla?  do  not 
rupture  at  once,  they  coalesce,  and  considerable  quantities  of  sero- 
purulent  fluid  collect  and,  follo^\^ng  the  law  of  gravitation,  form 
characteristic  flaccid  sacs,  instead  of  tense,  rounded  bulla;.  The  ulti- 
mate tendency  of  the  disease  is  to  denude  the  entire  corium.  This  is 
effected  not  only  by  the  formation  of  new  bulljp,  but  by  burrowing  at 
the  periphery  of  those  already  formed.  Upon  the  excoriated  surface 
feeble  attempts  at  epidermization  are  seen  side  by  side  with  the  for- 
mation of  small  abortive  bulte  in  the  imperfectly  generated  epidermis. 
The  discharge  also  dries  upon  the  denuded  surface  in  the  form  of 
crusts  having  a  sort  of  tile-like  arrangement  from  the  development  of 
fissures.  These  dried  crusts  are  shed  as  a  result  of  the  oozing  be- 
neath and  this  phenomenon  gives  the  disease  its  name.  Ultimately 
nearly  the  entire  integument  A\dth  the  visible  mucosa;  may  become 
involved,  but  death  often  occurs  Avhile  much  of  the  skin  is  still  intact 
along  with  the  mucosae.  In  advanced  cases  one  of  the  most  distressing 
symptoms  experienced  by  the  patient  is  a  sensation  of  constant  cold 
and  chilliness.  The  nails  and  hair  are  not  necessarily  lost,  but  the 
former  become  deformed  and  the  hair  shed  abundantly. 

Etielogy 

The  cause  of  the  disease  is  unknown.  Some  authorities,  however, 
believe  that  it  is  due  to  the  presence  of  a  toxin  circulating  in  the  blood 
and  that  the  cutaneous  manifestations  are  secondary. 

Diagnosis 

"When  the  mucosa;  are  involved  pemphigus  foliaceus  is  automat- 
ically differentiated  from  any  of  the  forms  of  universal  dermatitis. 

29 


There  are,  however,  cases  so  mild  that  one  would  hardly  be  likely 
to  associate  them  with  so  grave  a  condition.  The  flaccid  bullae,  and 
the  excoriated  surfaces  which  refuse  to  heal  are  sufficient  for  diagno- 
sis, but  since  the  lesions  at  first  may  respond  to  the  use  of  arsenic, 
the  practitioner  may  regard  the  affection  as  ordinary  pemphigus. 
Ultimately  the  disease  is  unmistakable  and  the  odor  is  so  characteris- 
tic that  a  diagnosis  can  often  be  made  from  a  considerable  distance. 

Prognosis 

This  is  always  grave. 

Treatment 

There  is  no  loiowTi  efficacious  treatment  and  considering  the  grav- 
ity of  the  disease  any  rational  form  of  experimental  therapy  is  fully 
justified.  Some  of  the  symptoms  may  be  relieved  by  local  treatment 
similar  to  that  employed  in  pemphigus  vulgaris. 

Attempts  should  be  made  at  active  disinfection  of  the  exposed 
surfaces,  for  at  present  we  do  not  know  how  much  of  the  fatal  ele- 
ments in  pemphigus  may  be  due  to  the  absorption  of  toxic  matter. 


Fig.  17.     Model  in  Neisser's  Clinic  in  Breslau  (Kroener), 

'SO 


Plate  12. 


\ 


\ 


\ 


Fig.  18.  Pemphigus  vegetans. 


Pemphigus  Vegetans 

Plate  12,  Fig.  18 

This  affection,  like  pemphigus  foliaceus,  is  best  described  inde- 
pendently ;  for  despite  the  fact  that  it  is  a  bullous  dermatosis,  it  was 
originally  not  classed  as  pemphigus,  and  it  is  largely  a  matter  of 
opinion  even  now  as  to  Avhether  it  should  be  so  regarded.  There  is 
no  doubt,  however,  that  it  shades  into  the  different  forms  of  pem- 
phigus. Exceptionally  pemphigus  vulgaris  and  pemphigoid  affec- 
tions may  assume  a  vegetating  character.  In  the  typical  disease, 
however,  pemphigus  vegetans  is  a  distinct  affection  from  the  outset. 
It  tends  to  attack  moistened  cutaneous  surfaces  and  the  visible 
mucosjE ;  and  to  this  peculiarity  is  to  be  attributed  the  fact  that  the 
excoriations  resulting  from  the  maceration  of  the  skin  tend  to  form 
condyloma-like  excrescences.  The  affection  therefore  markedly  re- 
sembles the  so-called  moist  syphilides ;  and  as  a  matter  of  fact  it  was 
originally  confounded  with  syphilis,  even  by  such  authorities  as 

Kaposi. 

This  resemblance  to  syphilis  is  so  pronounced  that  an  account  of 
pemphigus  vegetans  is  largely  a  matter  of  differential  diagnosis.  The 
disease  is  such  a  rarity  tliat  generalizations  are  hardly  wise ;  but  its 
most  pronounced  differential  feature  in  all  typical  cases  is  failure  to 
respond  to  treatment  of  any  sort.  A  lesion  of  pemphigus  vegetans  is 
to  all  extent  and  purposes  a  lesion  which  is  semi-malignant.  It  has 
no  tendency  to  heal  nor  can  it  be  made  to  heal.  In  many  cases  there  is 
an  added  tendency  for  the  lesions  to  generalize  from  the  moist  to  the 
dry  surfaces.  In  these  generalized  eases  there  is  an  undeniable  re- 
semblance of  the  lesions  to  those  of  ordinary  pemphigus.  The  vege- 
tating feature,  however  conspicuous,  is  perhaps  (like  the  continuous 
exfoliation)  merely  a  detail,  as  is  the  case  in  syphilis.  Death  in 
certain  cases  if  not  in  the  majority  is  due  to  some  intercurrent  or 
pre-existent  affection,  but  it  frequently  occurs  from  the  disease  it- 
self, possibly  as  the  result  of  exhaustion.  One  of  my  patients,  a 
woman  of  sixty,  died  three  months  after  the  appearance  of  lesions  in 
the  mouth.    She  was  well  nourished  and  at  autopsy  an  experienced 

81 


pathologist  was  unable  to  discover  any  visceral  lesion  that  would  in 
any  way  account  for  death. 

Etiology 

Aside  from  the  fact  that  most  of  the  victims  have  been  middle- 
aged  women,  some  of  whom  had  previously  contracted  syphilis,  but 
little  can  be  said  under  this  head.  There  is  no  apparent  connection 
with  gestation  or  with  the  nervous  system.  In  a  very  few  eases  the 
disease  may  have  represented  a  septic  infection,  which  lends  some 
color  to  the  hypothesis  of  a  crypto-genetic  sepsis.  Histologically  the 
vegetating  lesions  present  a  picture  very  much  like  that  of  syphilitic 
condylomata. 

Prognosis 

The  course  of  the  disease  is  much  like  that  of  pemphigus  foliaceus. 
In  typical  cases  the  patient  is  almost  sure  to  succumb  to  exhaustion 
within  a  year,  while  some  perish  as  early  as  two  months.  Cases  of 
reported  recovery  are  usually  found  to  be  those  which  were  distinctly 
atypical,  either  because  grafted  upon  ordinary  pemphigus,  or  some 
pemphigoid  eruption,  or  because  the  lesions  showed  no  tendency  to 
generalization. 

Treatment 

Although  arsenic  is  of  little  or  no  value  in  this  disease,  the  employ- 
ment of  salvarsan  is  worthy  of  trial.  Mercury  and  potassium  iodide 
do  not  appear  to  retard  the  progress  of  the  disease. 

Aside  from  the  general  desiccating  and  soothing  remedies  in  com- 
mon use  in  similar  cases  and  the  continuous  bath,  the  only  rational 
measure  ever  introduced  in  harmony  with  progressive  therapeutics 
is  disinfection,  which  is  performed  somewhat  as  in  extensive  burns. 
On  account  of  the  superficial  character  of  the  lesions  mild  measures 
may  suffice,  such  as  solutions  of  hydrogen  peroxide,  potassium  per- 
manganate and  Labarraque's  solution  in  proper  dilution.  These  may 
be  used  in  spray  form  or  on  saturated  cloths.  Carbolic  acid  solutions 
have  been  advised  whenever  the  danger  of  absorption  can  be 
minimized. 


Fig.  18.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

32 


Plate  13. 


Fi^.  19.  Pemphigus  acutus  neonatorum. 


Fig.  20.  Dermatitis  herpetiformis. 


Pemphigus  Neonatorum 

Plate  13,  Fu;.  1!J 

It  is  almost  universally  conceded  that  tins  is  a  pemphigoid  condi- 
tion having  absolutely  no  connection  -with  the  pemphigus  proper.  It 
has  several  sharply  defined  clinical  characteristics.  First  it  attacks 
the  newly  born  only;  second,  it  is  contagious,  and  tends  to  occur  m 
epidemics  in  maternity  hospitals;  third,  it  is  dependent  in  some  man- 
ner on  conditions  -svhich  favor  septic  infection,  and  is  often  associated 
Avith  septic  conditions  either  in  the  infants  themselves,  the  puerperal 
Avomen,  or  the  attending  physician  and  nurse.  Thus  it  may  be  re- 
garded as  one  member  of  a  group  disease — acute  sepsis  of  the  newly 
born,  which  comprises  such  other  members  as  umbilical  sepsis,  septic 
coryza,  septic  pneumonia,  buccal  sepsis,  etc.  Pemphigus  is,  in  fact, 
by  no  means  the  sole  type  of  cutaneous  sepsis  of  the  newly  born,  for 
under  this  head  are  commonly  placed  Ritter's  disease  (dermatitis 
V  exfoliativa  neonatorum) ;  ecthyma  (some  forms  of  which  cause  gan- 
)^~grene) ;  multiple  subcutaneous  abscesses,  etc.  Even  erysipelas  neona- 
torum has  been  placed  in  the  same  category.  Associated  with  all 
these  manifestations  w^e  find  the  ordinary  pus-exciting  microorgan- 
isms, which  are  commonly  held  responsible  for  puerperal  sepsis  in 
the  mother. 

The  mechanism  of  infection  presents  the  same  obscurity  in  the  in- 
fant as  in  the  mother.  The  pyogenic  microorganisms  are  no  doubt  in- 
oculable,  for  adults  sometimes  contract  bulUc  from  the  children. 
But  if  that  were  all  the  disease  signifies,  it  would  only  be  plain  im- 
petigo contagiosa.  The  latter,  as  stated  elsewhere,  is  not  knowTi  to 
cause  constitutional  infection  even  under  aggravated  conditions,  and 
is  never  regarded  as  in  any  sense  septic.  In  pemphigus  neonatorum, 
however,  a  large  proportion  of  the  children  are  already  septic  or  soon 
become  so.  If  the  bullse  are  regarded  as  primary  lesions,  some  consti- 
tutional reaction  should  occur,  but  that  they  should  form  a  port  of 
entry  for  germs  is  not  in  accordance  with  analogy.  It  is  more  likely 
that  cachectic  or  premature  children,  while  specially  prone  to  contract 
the  eruption,  in  reality  perish  from  other  causes;  or  that  some  more 
severe  form  of  sepsis  attacks  the  child  at  the  same  time.  That  the 
bullje  are  metastatic  is  not  to  be  believed,  for  skin  lesions,  secondary 
to  knoAVTi  sepsis,  are  very  rare  and  behave  in  a  very  different  manner. 

83 


To  understand  better  a  problematic  affection  of  this  sort,  the 
study  of  an  individual  epidemic  is  instructive.  In  tlie  fall  of  1906 
twenty-seven  babies  were  attacked  in  the  Lying-in  Hospital  of  the 
City  of  New  York.  The  great  majority  developed  the  affection  from 
the  fourth  to  the  seventh  day.  Nine  babies  died,  but  in  only  six 
cases  could  it  be  held  that  pemphigus  caused  death,  and  in  none  was 
there  evidence  of  general  sepsis.  The  more  severe  as  a  rule  the 
eruption,  the  graver  the  prognosis ;  in  other  words,  the  eruption  fur- 
nished an  index  of  severity,  arguing  the  existence  of  a  strong  predis- 
posing element.  The  absence  of  fever  in  some  of  the  worst  cases 
seemed  to  indicate  a  profound  toxemia  of  the  sore  sometimes  seen  in 
rapidly  fatal  diseases.  In  certain  cases  contagion  could  be  showm. 
Staphylococci  could  be  cultivated  from  the  bullae.  None  of  the 
mothers  were  septic.  H.  J.  Schwartz,  who  describes  the  preceding, 
is  inclined  to  believe  that  toxins  formed  by  the  local  suppuration 
caused  death  in  the  fatal  cases,  and  it  is  possible  that  in  this  as  in 
similar  maladies  a  toxic  substance  is  produced  in  the  skin  analogous 
to  that  now  known  to  be  the  essential  cause  of  death  after  burns. 
Such  cases  at  least  suggest  the  possibility  of  a  fatal  component  which 
has  no  connection  with  sepsis.  At  the  other  extreme  are  innocent 
cases,  in  all  respects  resembling  impetigo  contagiosa,  which  tend  to 
appear  about  the  navel  only  (periumbilical  pemphigus).  In  certain 
cases  this  mild  type  becomes  the  starting  point  for  the  ordinary 
severe  form. 

The  eruption  of  pemphigus  neonatorum  in  typical  cases  appears 
within  the  first  fortnight  of  life,  and  without  any  regular  sequence. 
The  blebs  may  be  few  or  many,  and  in  the  worst  cases  become  con- 
fluent in  certain  localities,  denuding  large  quantities  of  skin. 

Diagnosis 

This  shoidd  give  no  trouble.  The  usual  proof  is  secured  by  culti- 
vation of  one  of  the  pyogenic  cocci  from  the  serum  of  the  bullse. 

Treatment 

But  little  can  be  said  under  this  head.  The  infant  should  be  iso- 
lated and  placed  under  all  available  hygienic  conditions.  The  bullae 
should  be  punctured  and  treated  with  soothing  antiseptic  dressings. 
In  severe  cases,  however,  local  treatment  is  of  little  avail.  Too  much 
stress  cannot  be  laid  upon  the  necessity  for  early  and  complete  isola- 
tion, as  the  contagious  nature  of  the  disease  is  now  fuUy  recognized. 

Pig.  19.     Model  in  Lesser's  Clinic  in  Berlin  {Kolhow). 

34 


Plate  14. 


Fig.  21.  Dermatitis  herpetiformis. 


Dermatitis  Herpetiformis 

Synonyms:    Duhring's  disease;  Hydroa  herpetiforme,  Pemphigus 

pruriginosis 

Pkite  13,  Fig.  20;  Plate  14,  Fig.  21 

This  affection  was  first  described  as  such  by  Duhring,  but  it  was 
evidently  familiar  to  many  of  his  predecessors  under  other  designa- 
tions. It  is  a  highly  multiform  affection,  and  one  of  the  commonest 
features  of  the  eruption  is  the  presence  of  clusters  of  herpes-like 
vesicles.  It  may  present  any  ciita-uMms  losinn  s;ivc  ulceration,  and 
sooner  or  later  is  followed  by  tl'ij)  pigmentation. 

The  great  possihUi-tlcs  i'or  dil'lVronce  in  type  in  individual  cases 
made  it  a  difficult  disease  to  describe,  and  tliis  probably  accounts  for 
the  delay  in  its  recognition  as  a  clinical  entity. 

In  young  children  it  may  be  wholly  vesicular  or  bullous ;  and  in 
some  of  the  worst  cases  in  adults  the  lesions  may  consist  of  e^r^^jepaa- 
tous  patches  and  papules  or  vesicopapules.  As  a  rule  consecutive  at- 
tacks present  flie  same  lesions  as  the  first  outbreak,  so  that  some 
would  divide  the  disease  up  into  several  distinct  types.  Itching  is  said 
to  be  most  intense  during  the  evolution  of  an  outbreak.  According  as 
the  outbreaks  succeed  one  another  rapidly  or  with  long  pauses,  the 
appearance  of  the  case  ^\•ill  vary.  In  the  former  case  it  is  more 
likely  to  be  generalized,  as  in  the  opposite  instance  many  lesions  will 
disappear.  When  the  lesions  do  not  proceed  beyond  the  erythematous  \ 
stage  the  eruption  is  said  to  resemble  greatly  erythema  multiforme 
when  that  affection  is  generalized. 

The  question  naturally  arises  as  to  whether  there  are  any  charac- 
teristics which  belong  especially  to  this  one  disease.  Is  there  any- 
thing characteristic  of  the  individual  lesions?  The  large  vesicles  and 
bullae  show  peculiar  outlines.  Instead  of  being  rounded  or  oval  they 
are~angular,  polyhedral,  elongated  and  in  general  show  great  irre- 
gularily.  They  are  also  grouped  closely  together  and  otherwise  re- 
semble groups  of  herpes  vesicles.    The  groups,  however,  are  often 

35 


very  large — often  as  large  as  the  palm  of  the  hand,  and  even  occur  in 
large  sheets.  Then,  again,  a  large  portion  of  an  entire  limb  may  be 
studded  with  more  or  less  discrete  lesions.  As  with  pemphigus,  the 
mucous  membranes  may  sutler.  It  can  hardly  be  claimed  that  there 
are  any  true  localities  of  preference.  Like  those  of  pemphigus,  its 
lesions  may  appear  almost  anywhere. 

Etiologj/ 

The  same  neurotic  element  is  present  here  that  we  have  already 
seen  in  pemphigus.  Also  the  autotoxic  and  septic  factors,  and  it  is 
highly  probable  that  the  neurotic  element  may  depend  on  the  presence 
of  a  toxin  in  the  blood.    Eosinophilia  isjnyariably  iiresent,  as  well  as 

^  ,  indicanuria. 

(^  Histologic  study  throws  no  light  on  the  nature  of  the  disease. 

Diagnosis 

When  first  seen,  and  especially  during  the  early  outbreaks,  a  diag- 
nosis is  often  difficult,  because  the  multiform  nature  causes  it  to  simu- 
late so  many  other  conditions.  The  diagnosis  is  often  left  open  until 
the  case  can  be  studied  thoroughly.  In  the  erythematous  and  papulo- 
vesicular stages,  the  affection  is  readily  confused  with  eczema  or  ery- 
thema multiforme,  some  authors  to  the  contrary  notwithstanding. 
Intense  itching,  refractoriness  to  treatment,  occurrence  in  suQfiessive 
cro£s_and  marked  pigmentation  causTsuspicion  of  dermatitis  herpeti- 
formis. However,  if  the  characteristic  vesicles,  bullae  or  pustules  are 
'  present,  the  correct  diagnosis  is  at  once  suggested. 

Prognosis 

This  should  be  guarded,  as  the  disease  is  essentially  a  chronic  one. 
Still,  many  cases  improve  notably,  doubtless  as  a  result  of  general 
treatment. 

Treatment 

In  a  persistent  disease  like  dermatitis  herpetiformis,  hygienic 
measures  are  of  great  importance.  Everything  possible  should  be 
done  to  relieve  or  avoid  strain  upon  the  nervous  system.  Best,  free- 
dom from  work  and  worry,  and  particularly  a  change  of  surroundings, 
are  indicated.  Articles  of  diet  which  are  prone  to  cause  fermentative 
changes  in  the  intestines,  thereby  increasing  autointoxication,  should 
be  interdicted.  Internal  medication  should  be  directed  chiefly  toward 
improving  the  patient's  general  health.    Tonics  such  as  strychnia, 

86 


i)C 


V- 


quinia,  phosphorus,  iron  and  cod-liver  oil,  may  be  used.  Of  all 
remedies,  however,  arsenic,  judiciously  administered,  is  the  most 
valuable.  It  acts  almost  as  a  specific  in  some  cases,  particularly  those 
offi^jvesicular  or  bullous  type.  The  dose  should  be  increased  grad- 
ually until  the  disease  shows  signs  of  yielding,  or  the  well-recognized 
symptoms  of  arsenical  toxemia  appear.  The  prolonged  administra- 
tion of  arsenic  is  not  to  be  endorsed,  and  its  ability  to  promote 
epithelial  growth  should  be  kept  in  mind.  Crocker  prefers  salicin  to 
arsenic,  and  recommends  that  it  be  given  three  times  a  day  in  doses 
of  from  fifteen  to  thirty  grains.  Potassium  permanganate  in  one- 
grain  doses,  in  capsules,  taken  after  meals,  was  of  apparent  benefit 
in  a  number  of  my  cases. 

Locally,  any  of  the  antipruritic  and  antiphlogistic  applications 
may  render  aid.  For  the  pruritus,  solutions  of  ichthyol,  potassium 
permanganate,  or  liquor  picis  alkalinus  are  of  considerable  value. 
The  following  lotion  is  particularly  serviceable  in  extensive  eruptions 
■ftdth  a  good  deal  of  inflammation : 

IJ  Acidi   carbolici    oi 

Pulv.  calamine  prep 3ii 

Zinci  oxidi oiv 

Glycerini    5vi 

Aquse  calcis ,^i 

Aqua;  rosw ad  oviii 

M.  Et   ft.  lotio. 

Ointments,  as  a  rule,  are  of  less  value,  althoiigh  good  results  are 
generally  obtained  from  the  use  of  mild  sulphur  ointment,  as  first  rec- 
ommended by  Buhring  himself. 


Fig.  20.     Model  in  St.  Louis  Hospital  in  Paris,  No.  1352  (Baretta). 

Tenneson's  case. 

Fig.  21.    Model  in  Dcrmatological  Clinic  in  Freiburg  (Vof/dbacher). 

87 


Urticaria 

Synonyms:    Hives,  Nettle  rash 
Plate  15,  Fig.  22;  Plate  16,  Fig.  23;  Plate  17,  Figs.  24  and  25 

This  affection  must  be  regarded  in  a  twofold  manner.  First  as 
an  innate  peculiarity  of  certain  skins,  in  virtue  of  which  wheals  may 
be  produced  at  a  point  of  irritation.  To  a  certain  extent  this  is  not 
a  peculiarity,  for  it  resides  in  all  skins.  Thus  the  mosquito,  bedbug, 
body  louse  and  other  insects  produce  wheals  in  all  or  nearly  all  by 
their  bites.  In  some  individuals  lesions  are  produced  by  contact  with 
jelly-fish.  The  point  of  a  hypodermic  or  of  an  electric  epilating 
needle  very  often  causes  a  small  wheal.  A  high,  specialized  degree  of 
this  behavior  is  seen  in  urticaria  factitia  and  dermographism.  These 
manifestations  may  be  produced  at  will  in  some  subjects.  Thus 
whipping  with  nettles  will  bring  out  a  crop  of  wheals,  and  by  dermo- 
graphism is  meant  that  artificial  wheals  may  be  determined  in  lines, 
curves,  etc.,  so  that  writing  may  be  produced.  Other  skins  behave 
in  this  manner  only  during  an  acute  general  outbreak  of  urticaria. 

Secondly,  urticaria  must  be  regarded  as  an  acute  generalized 
dermatosis  of  internal  origin,  of  the  exanthem  type,  characterized 
by  the  evolution  of  evanescent  white  or  reddish  wheals,  during  which 
there  is  much  subjective  disturbance — bitching,  burning,  etc.  Attacks 
may  succeed  one  another  in  crops.  The  entire  skin  and  visible  mu- 
cosae may  be  involved,  and  it  is  highly  probable  that  an  analogous 
disturbance  occurs  in  the  viscera. 

There  are  numerous  types  of  this  affection.  In  the  simplest  and 
most  familiar  form  there  is  a  single  crop  of  wheals  which  comes 
and  goes  in  a  few  hours,  the  lesions  being  of  pea  or  bean  size;  or 
the  evolution  may  be  slower  and  somewhat  irregular,  so  that  wheals 
are  in  evidence  for  several  days.  In  rare  instances  the  evolution 
of  wheals  is  almost  continuous,  although  the  individual  lesions  come 
and  go  rapidly.  The  condition  is  then  called  urticaria  chronica.  In 
certain  eases  the  wheals  are  represented  by  small  papules  closely  ag- 
gregated.   While  these  manifestations  are  usually  comprehended 

88 


Plate  15. 


Fig.  22.  Urticaria. 


Plate  16. 


Fig.  23.  Urticaria  chronica  infantum. 


Plate  17. 


Fig.  24.  Urticaria  rubra. 


Fig.  25.  Urticaria  pigmentosa. 


under  urticaria  factitia,  they  may  occur  spontaneously,  as  a  result  of 
some  internal  condition.  They  are  then  largely  peculiar  to  the  irri- 
table skins  of  children  and  may  be  disseminated  over  the  liml)s.  They 
resemble  a  papular  eczema  greatly,  but  their  urticarial  nature  is 
sho^\^l  by  their  evanescence.  They  are  apt  to  occur  over  a  period  of 
several  weeks. 

Urticaria  with  large  wheals  is  not  uncommon,  large  red  or  white 
wheals  being  often  associated  with  smaller  ones.  Sometimes  several 
large  wheals  are  closely  approximated,  forming  a  large  firm  swelling 
which  resembles  confluent  insect  bites.  A  minute  hemorrhagic  point 
in  the  centre  increases  the  illusion.  Large  wheals,  forming  edematous 
tumors,  are  kno\\Ti  as  giant  urticaria.  Urticaria  may  be  complicated 
with  purpura  (urticaria  ha^morrhagica)  and  there  is  also  a  bullous 
type  of  urticaria  (urticaria  bullosa). 

Urticaria  pigmentosa  (Fig.  25),  usually  regarded  as  a  separate 
affection,  may  be  mentioned  here.  In  this  affection  the  eruption  is 
characterized  by  the  usual  wheals,  but  these  do  not  undergo  the  usual 
involution.  Instead  they  tend  to  persist  indefinitely  and  a  deposit  of 
pigment  occurs  which  is  virtually  permanent.  The  affection  is  almost 
peculiar  to  infants  and  children.  The  stains  are  not  due  to  such 
familiar  causes  as  hemorrhage  and  scratching,  but  seem  to  be  part 
of  a  new  formation  of  tissue,  as  an  integral  element  in  the  disease, 
which,  while  it  is  but  little  affected  by  treatment,  is  usually  outgrown 
at  puberty. 

Etiologv 

Urticaria  has  some  deep-seated  connection  with  the  vasomotor 
system,  and  has  affinities  with  the  vasomotor  neuroses.  The  first 
step  in  the  formation  of  a  wheal  is  angiospasm  causing  an  area  of 
local  anemia.  This  spasm  is  followed  by  sudden  vaso-dilatation  and 
effusions,  which  compresses  the  vessels  from  without.  This  causes  a 
white  wheal  with  an  outlying  hyperemic  zone.  The  process  resembles 
somewhat  the  formation  of  the  lesions  in  erythema  multiforme.  It 
is  evident  that  the  actual  cause  of  the  disease  is  that  which  tends  to 
induce  this  angiospasm,  and  this  is  commonly  a  circulating  toxin 
absorbed  from  the  alimentary  canal.  Many  familiar  dietetic  articles 
can  cause  it,  the  best  knowm  being  shellfish,  mushrooms,  and  straw- 
berries. In  many  cases  there  is  no  evidence  to  point  to  any  one 
substance,  but  simply  a  gastro-enteric  crisis  due  to  general  dietetic 
abuses.  In  urticaria  of  intestinal  origin,  the  intestinal  tract  may 
suffer  as  well,  as  a  result  of  direct  irritation  from  the  toxic  sub- 

89 


stance.  So-called  idiosjaicrasy,  in  which  the  consumption  of  a  cer- 
tain drug  or  dietetic  article  is  invariably  followed  by  urticaria,  is 
best  explained  by  anaphylaxis — supersensitiveness  to  the  particular 
substance  caused  by  the  original  unpleasant  experience  with  it.  For 
this  reason  it  may  be  very  dangerous  for  these  subjects  to  make 
use  of  these  substances  at  all,  for  the  oversensitiveness  may  so  in- 
crease, that  the  so-called  anaphylactic  shock  may  prove  fatal,  espe- 
cially in  individuals  with  advanced  cardiac  disease. 

Diagnosis 

Urticaria  in 'its  simpler  form  is  readily  recognizable  even  by  the 
laity,  who  know  it  under  such  names  as  "hives"  and  "nettle  rash." 
Chronic  urticaria,  on  the  contrary,  is  easily  misjudged.  It  is  neces- 
sary to  watch  for  new  lesions,  and  when  these  are  found  to  be  wheals 
the  diagnosis  is  easy.  Giant  urticaria  may  readily  be  taken  for  some 
local  lesion,  the  result  of  insect  bites,  for  example;  the  more  so 
because  it  may  be  limited  to  some  one  area.  These  cases  are  usually 
regarded  as  a  transition  between  urticaria  and  acute  circumscribed 
edema. 

Treatment 

If  an  acute  attack  is  seen  at  the  outset,  a  quickly  acting  purgative 
should  be  given ;  usually  one  of  the  salines.  Antacids  are  also  given. 
This  plan  should  be  pursued  whether  vomiting  and  diarrhea  are 
present  or  absent.  Any  other  detoxicating  measures  available  should 
be  practised,  and  this  plan  of  management  should  be  kept  up  for 
several  days.  Intestinal  antiseptics,  colonic  irrigation,  and  simple, 
bland  diet  are  comprised  in  the  management.  Some  writers  advise 
salol  in  regular  doses  for  its  supposed  antifermentative  properties. 
A  combination  of  alkaline  diuretics  and  bromides  appears  to  aid 
in  controlling  the  disease.  Johnston  recommends  the  administration 
of  ichthyol  in  five-grain  capsules  after  meals.  This  he  regards  as 
the  most  serviceable  drug  for  internal  medication  at  our  command. 

Locally  the  antipruritics  and  sedative  measures  used  in  acute  dif- 
fuse eczema  are  indicated. 

Medicated  baths  frequently  allay  the  cutaneous  irritation  and 
inflammation.  An  excellent  formula,  recommended  by  Bulkley,  is  the 
following : 

^  Potassii  carbonatis §iv 

Sodii  carbonatis 3"i 

Pulveris  boracis 3" 

M.  Use  in  a  thirty-gallon  bath,  with  a  pound  or  two  of  starch. 

40 


Owing  to  the  volatile  character  of  the  lesions  sediment  lotions  are 
generally  inferior  to  ointments. 

In  recurrent  and  chronic  urticaria  the  management  is  summed 
up  under  rigorous  intestinal  disinfection,  including  a  carefully  se- 
lected diet,  and  some  of  the  same  tonic  measures  as  are  applied  in 
dermatitis  herpetiformis. 


Fig.  22.  Model  in  Neisser's  Clinic  in  Breslau  {Kroener).  Man,  thirty 
years  of  age,  suffering  from  chronic  urticaria  for  one  year  previous  to 
the  time  when  the  model  was  made. 

Fig.  23.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

Fig.  24.     Model  in  Neisser's  Clinic  in  Breslau  {Kroeiur). 

Fig.  25.  Model  in  Neisser's  Clinic  in  Breslau  (Krociur).  Boy,  two  years 
old,  suffering  also  from  tetany.  The  affection  distributed  over  the 
entire  body;  skin  reflexes  exaggerated;  factitious  urticaria  over  the 
entire  skin. 

41 


Dermatitis  Medicamentosa 

Plates  18  to  22,  Figs.  26  to  33 

This  term  is  employed  to  denote  outbreaks  caused  by  the  internal 
administration  of  drugs,  and  is  not  to  be  confused  with  the  various 
forms  of  dermatitis  venenata  caused  by  the  external  application  of 
remedies.  Drug  eruptions  do  not  differ  essentially  from  dermatoses 
due  to  supposed  autotoxications  and  metabolic  disorders.  In  either 
case  all  the  primary  and  secondary  lesions  may  be  represented,  and 
marked  polymorphism  is  sometimes  seen.  These  drug  rashes  may 
also  closely  simulate  the  exanthems  of  acute  infectious  diseases.  Nor 
are  lesions  due  to  drugs  limited  to  mere  acute  efflorescences,  for  cer- 
tain medicaments  can  produce  chronic,  productive  and  destructive 
lesions  like  the  granulomata.  Arsenic  can  cause  an  overproduction  of 
horny  epithelium,  sometimes  resulting  in  a  malignant  growth. 

A  very  important  distinction  must  be  made  between  customary 
action,  supersensitiveness,  and  idiosyncrasy  in  respect  to  this  action 
of  drugs  on  the  skin.  The  term  idiosyncrasy  should  not  be  confound- 
ed with  supersensitiveness,  for  it  implies  something  peculiar  to  the 
individual  and,  perhaps,  his  blood  relatives.  The  idea  of  supersensi- 
tiveness has  received  a  great  impetus  in  recent  years  from  the  study 
of  anaphylaxis.  Supersensitiveness  may,  of  course,  be  innate  in  a 
subject,  but  it  is  often  the  result  of  a  poisoning  on  some  previous  occa- 
sion which  has  rendered  the  skin  supersensitive  to  the  substance  in 
question.  Anaphylaxis  may  also  result  locally,  and  the  sensitiveness 
to  poison  ivy  and  the  like  is  doubtless  in  part  anaphylactic.  A  sub- 
ject supersensitive  to  one  drug  may  very  likely  be  supersensitive  to 
others.  No  doubt  there  is  a  general  predisposition  to  drug  eruptions 
based  on  unusual  vasomotor  irritability,  and  hence  noted  chiefly  in 
children,  certain  women  and  neurotic  subjects.  Defective  elimination 
has  the  same  significance  as  overdoses,  and  certain  drug  lesions  ap- 
pear to  have  resulted  from  proved  renal  insufficiency  in  elimination. 

A  factor  of  great  importance  is  that  the  rash,  etc.,  provoked  by 
a  given  medicament  is  not  always  connected  with  its  true  cause,  so 

42 


Plate  18. 


Fig.  26.  Dermatitis  Medicamentosa  (Antipyrine  rash). 


Fig.  27.  Dermatitis  Medicamentosa  (Arsenic  rasli). 


that  the  patient  continues  the  use  of  the  drug  until  a  more  or  less 
serious  condition  results. 

Few  drugs  exert  tlieir  toxic  action  peculiarly  on  the  skin.  It  must 
be  borne  in  mind  that  otlier  tissues  are  usually  implicated,  and  that 
the  offending  substance  leaves  the  body  in  the  urine,  in  which  it  may 
often  be  detected. 

In  some  instances  a  drug  which  is  eliminated  by  the  skin  may«come 
in  contact  with  another  locally  employed.  A  cTiemical  reaction  may 
result,  causing  some  local  disturbance.  The  action  of  light  on  metal- 
lic salts  wliich  are  in  the  circulating  blood  may  also  cause  special 
phenomena,  especially  of  the  nature  of  discoloration  of  the  skin. 

A  question  naturally  arises,  are  drug  rashes  to  some  extent  the 
effects  of  elimination  by  the  skin  ?  There  is  little  direct  evidence  as 
to  the  correctness  of  this  speculation,  but  beyond  the  fact  that  these 
substances  are  in  the  circulating  blood  nothing  is  really  kno^vn  as  to 
their  modus  operandi. 

A  drug  eruption  is  recognized  as  such  only  by  the  crucial  test  of 
exhibiting  the  drug  on  a  second  occasion.  Its  known  action  on  the 
supersensitive  usually  gives -sufficient  information.  It  is  possible,  by 
combining  certain  antagonistic  drugs,  to  prevent  many  drug  erup- 
tions, but  there  is  hardly  any  special  treatment,  save  in  severe  chronic 
cases,  to  be  mentioned  later. 

Following  are  some  of  the  leading  drugs  which  cause  lesions  and 
their  symptoms: 

Aniipyrin  (Fig.  26) 

This  drug  does  not,  as  a  rule,  cause  anaphylaxis,  but  the  contrary, 
as  many  become  immune.  It  causes  a  general  outbreak,  but  as  a  rule 
the  face  and  trunk  bear  the  brunt.  The  rash  may  be  morbilliform, 
searlatinaform  or  polymorphous.  In  rare  cases  bulhc,  purpura,  and 
pustules  have  been  noted.  A  feature  of  especial  significance  is  pig- 
mentation following  the  eruption. 

Arsenic  (Fig.  27) 

This  drug  is  believed  to  have  an  elective  action  on  the  skin,  and 
the  number  and  variety  of  its  collateral  phenomena  are  too  great  even 
to  enumerate.  Arsenic  can  cause  a  typical  herpes  zoster,  keratosis  of 
the  palms  and  soles,  gangrene  of  the  scrotum,  pigmentation,  "and  even 
epithelioma.  The  general  pigmentation  that  frequently  follows  the 
continued  use  of  arsenic  is  often  mistaken  for  Addison's  disease. 

48 


Bromine  (Fig.  29) 

These  salts  affect  nearly  all  subjects.  Bromie  acne  is  much  like 
the  ordinary  form,  but  has  a  tendency  to  confluence,  producing  a  sort 
of  small  carbuncle.  In  mild  cases  lesions  are  rather  confined  to  the 
face  and  shoulders,  as  in  acne  proper.  In  bromism  supervening  sud- 
denly upon  large  doses  the  thighs  are  a  favorite  locality,  and  hardly 
any  region  is  immune.  In  certain  cases  the  papillary  layer  of  the 
skin  seems  to  be  stimulated,  so  that  fungoid  outgrowths  are  produced 
without  previous  ulceration.  Cutting  off  the  drug  may  not  be  fol- 
lowed at  once  by  improvement.   Lesions  may  even  continue  to  appear. 

Chloral  Hydrate 

A  typical  drug  rash  not  infrequently  follows  its  use.  A  scarla- 
tinoid exanthem,  implicating  the  mucosa?,  and  succeeded  by  desquama- 
tion, is  well  known.  Various  anomalous  rashes  also  occur,  as  in  the 
use  of  other  drugs. 

Chlorine  (Fig.  32) 

Workers  in  this  gas  often  suffer  from  an  acne-like  affection,  be- 
lieved, however,  to  result  from  outward  exposure,  at  least  in  part. 

Copaiba  (Fig.  28) 

A  peculiar  erythematopapular  universal  efflorescence  is  often 
seen  in  gonorrheal  subjects  who  are  using  the  balsam.  This  rash 
serves  greatly  to  obscure  the  fact  that  gonorrhea  itself  can  cause  an 
exanthem. 

Iodide  of  Potassium  (Figs.  30-31) 

An  acne-like  eruption,  much  like  that  of  bromine  salts,  is  pro- 
duced by  this  drug,  and  exceptionally  the  usual  irregular  outbreaks 
seen  with  drugs  in  general  (buUaj,  purpura,  etc.).  There  is  also  a 
peculiar  confluent,  patchy  lesion,  somewhat  similar  to  a  bromine  "car- 
buncle," but  more  indolent,  which  seems  to  be  due  to  a  congeries  of 
inflamed  follicles,  and  occurs  on  the  legs  as  a  rule.  There  is  also  a 
severe,  proliferative,  and  destructive  affection,  much  resembling  the 
infectious  granulomata,  seen  on  the  upper  extremities  and  elsewhere. 
In  this  form  a  tendency  to  buUas  exists,  and  is  a  leading  factor. 

These  severe  forms  of  iodism  have  sometimes  been  brought  in  re- 
lation with  renal  and  cardiac  insufficiency,  but  have  also  been  seen 
in  apparently  vigorous  youthful  subjects. 

44 


Plate  19. 


Fig.  28.  Dermatitis  Medicamentosa  (Copaiba  rash). 


Plate  20 


■a 
o 


G 


o 


bjD 


CI 

c 


G 
Q 

bi) 


Plate  21. 


CO 

l-H 

<L> 

IS 

o 


c 

(U 

E 

CO 

-3 


CO 

E 
Q 

CO 


•a 
o 


to 
o 


E 

CO 

o 


CO 

E 

Q 


en 


Plate  22. 


Fig.  33.  Dermatitis  Medicamentosa  (Mercury  rash). 


Mercury  (Fig.  33) 

Erytliematous  eruptions  sometimes  occur  after  the  internal  ad- 
ministration of  mercury.  They  may  be  partial  or  general.  The  rash 
is  of  a  deep  red  color  and  is  often  accompanied  by  swelling  and 
pruritus.  Occasionally  it  may  be  papular  or  scarlatiniform,  and  in 
the  latter  case  is  generally  followed  by  desquamation. 

Quinia 

Cinchonism  is  sometimes  expressed  by  eruptions  of  the  same  type 
as  those  due  to  antipyrin. 

In  addition  to  the  preceding,  rashes  and  other  manifestations 
have  been  seen  after  a  great  variety  of  drugs:  aconite,  acetanilid, 
alcohol  (sometimes  causes  a  desquamating  erythema),  antimony,  ben- 
zoic and  boric  acids,  calx  sulphurata,  cannabis  Indica,  chloroform, 
cubebs,  digitalis,  ergot  (not  including  severe  ergotism),  opium  (pru- 
ritus a  very  conmion  sequence),  phenacetin,  rhubarb,  salicylic  acid 
and  derivatives,  sulphonal,  turpentine,  and  numerous  others. 


Fig.  26.  Model  in  Freiburg  Clinic  (Johnsen).  An  old  medical  man,  who, 
after  every  dose  of  migranin,  gets  circumscribed  urticarial  eruptions 
on  the  buttocks,  legs,  shoulders  and  mucous  membranes,  which  disap- 
pear after  about  a  fortniglit,  leaving  pigmentation. 

Fig.  27.     Model  in  Freiburg  Clinic  (Johnsen). 

Fig.  28.     Model  in  Neumann's  Clinic  in  Vienna   (Hennlng).     An   hemor- 
rhagic eruption  after  copaiba. 

Fig.  29.    Model  in  Neisser's  Clinic  in  Breslau  (Kroencr). 

Fig.  30.     Model  in  Lesser's  Clinic  in  Berlin  (Kolbow). 

Figs.  31  and  32.     Models  in  Freiburg  Clinic  (Johnsen). 

Fig.  33.     Model  in  Neisser's  Clinic  in  Breslau  (Kroener). 

46 


Lichen  Simplex  Chronicus  Vidal 

Synonym :    Neurodermatitis 

Plate  23,  Fig.  34 

This  affection,  unlike  true  lichen,  is  an  extremely  chronic  one.  It 
attacks  by  preference  the  neck,  the  inner  surface  of  the  upper  parts 
of  the  thighs,  and  the  flexor  folds  of  the  knees  and  elbows.  Excep- 
tionally the  abdomen  may  be  affected.  The  lesions  are  papules  of  the 
simple  lichen  type,  equivalent  to  those  often  seen  in  eczema.  They 
are  naturally  discrete  but  readily  become  confluent.  Well  marked 
cases  show  a  central  area  of  lichenification  of  a  grayish-brown  color, 
which  is  surrounded  by  a  brighter  zone  in  which  are  present  small, 
slightly  scaly  lichenoid  papules.  Vidal  claimed  that  the  disease  is 
essentially  a  pruritus  and  that  the  cutaneous  manifestations  are  due 
entirely  to  the  results  of  scratching — hence  an  artefact,  or  form  of 
dermatitis,  confined  largely  to  the  pilous  follicles.  The  deep  red, 
angry  look  of  the  papules,  if  not  the  lesions  themselves,  he  ascribed 
to  rubbing  and  scratching. 

Etiology 

The  disease  affects  only  neurotic  individuals  and  is  more  frequent 
in  women  than  in  men. 

Diagnosis 

This  should  not  be  difficult  in  a  fully  developed  case.  It  is  dis- 
tinguished from  other  similar  conditions  by  the  duration,  localization, 
and  absence  of  marked  inflammatory  phenomena. 

Prognosis 

The  condition  is  chronic  in  the  sense  that  new  outbreaks  constantly 
occur. 

Treatment 

General  measures  directed  to  the  relief  of  the  pruritus  are,  of 
course,  indicated.  The  local  treatment  is  essentially  that  of  chronic 
eczema.  In  severe  cases  chrysarobin  ointment  is  often  of  considerable 
benefit.    Solutions  of  oil  of  cade  are  also  useful. 

Fig.  84.    Model  in  Neisser's  Clinic  in  Breslau  (Kroener). 

46 


Plate  23. 


Fig.  34.   Lichen  simplex  chronicus  (Vidal). 


Fig.  35.  Pityriasis  rubra  pilaris. 


Pityriasis  Rubra  Pilaris 

Plate  23,  Fio.  35 

This  affection  appears  to  be  a  dermatitis  involving  the  hair-fol- 
licles. It  is  extremely  persistent  and  has  no  particular  secondary 
tendencies.  Unlike  types  of  folliculitis,  it  may  involve  the  entire  sys- 
tem of  hair-follicles  of  the  smooth  as  well  as  the  hairy  skin,  producing 
large  sheets  of  inflamed  integument  and  becoming  practically  univer- 
sal in  certain  cases.  The  separate  papules,  however,  can  always  be 
distinguished.  Considerable  fine  desquamation  is  present,  hence  the 
use  of  the  term  pityriasis.    General  scaling,  however,  does  not  occur. 

An  incipient  case  naturally  presents  a  different  picture  from  one 
well  advanced,  for,  as  a  rule,  the  disease  begins  in  a  limited  area, 
and  sometimes  remains  there.  Such  areas  are  the  scalp,  and  the 
palms  and  soles.  In  the  latter  localities  there  may  be  only  callous 
thickenings,  while  in  the  scalp  ordinary  or  seborrheic  eczema  may  be 
simulated.  Lesions  then  appear  in  various  other  localities — as  the 
fingers,  forearms,  trunk,  etc.,  where  their  development  may  be  readily 
studied.  The  papules  may  be  red  or  they  may  have  a  brownish  or 
grayish  color.  Each  follicle  may  be  the  seat  of  a  smaU  hard  central 
plug  as  well  as  a  hair-stump.  As  they  become  confluent  the  corium 
shows  participation.  It  becomes  thicker  and  less  supple,  and  may 
crack  slightly  at  the  natural  folds.  "Wlien  the  entire  face  is  involved 
there  may  be  some  retraction  about  the  orifices.  Alopecia  does  not 
result,  but  the  nails  may  become  brittle.  It  is  one  of  the  few  der- 
matoses able  to  implicate  practically  the  entire  integument.  The 
thickening  of  the  skin  gives  the  latter  a  coarsely  granular  appearance. 

Etiology 

The  affection  is  rare,  and  its  nosologic  position  has  been  much  de- 
bated. It  was  once  believed  to  be  the  same  disease  as  lichen  ruber 
acuminatus.  A  stumbling-block  was  the  high  mortality  of  the  latter 
as  described.  But  at  Vienna,  where  fatal  liclien  ruber  was  first  noted, 
no  fatalities  or  even  cases  of  marked  severity  are  now  recorded,  nor 
has  any  fatal  type  been  seen  for  years.    For  a  time  it  was  believed 

47 


that  lives  were  saved  only  by  the  heroic  use  of  arsenic,  but  this  was 
doubtless  a  misapprehension,  and  it  is  not  improbable  that  some  of 
the  recorded  deaths  resulted  from  the  misuse  of  .this  drug.  Arsenic 
now  seems  to  have  little  or  no  power  over  the  disease. 

Nothing  whatever  is  known  as  to  its  causal  elements.  It  may  be- 
gin in  childhood,  and  is  an  affection  of  early  life.  It  shows  no 
familial  incidence,  and  occurs  in  the  sound  and  vigorous.  As  a  hy- 
perkeratosis, which  it  appears  to  be,  with  inflammatory  phenomena 
purely  secondary,  it  shows  an  affinity  with  psoriasis.  The  reaction  of 
the  corium  to  the  epidermal  process  is  similar.  The  very  participa- 
tion of  the  entire  follicular  system  seems  to  coimect  it  with  some  fun- 
damental error  of  development. 

Diagnosis 

At  the  very  outset  lichen  rubra  pilaris  might  be  suggested,  or  ordi- 
nary dandruff  and  callosities.  As  the  disease  develops  there  shoidd 
be  no  further  trouble  in  identifying  it  until  it  becomes  universal.  The 
papules  are  usually  seen  in  a  typical  state  on  the  backs  of  the  fingers. 
Since  the  affection  has  been  made  a  congener  of  lichen  planus,  it  is 
evident  that  the  two  could  be  confused,  especially  as  in  lichen  planus 
the  papules  are  not  invariably  flattened.  The  initial  lesions,  however, 
are  so  typical  in  each  affection  that  confusion  should  hardly  occur. 
When  the  eruption  becomes  universal,  psoriasis  and  eczema  may  be 
simulated,  but  the  elementary  lesions,  and  especially  the  evolution  of 
the  disease,  should  prevent  confusion. 

Prognosis 

Arrest,  spontaneous  cure,  cure  by  treatment,  all  occur.  Recur- 
rence also  occurs,  and  in  many  cases  the  tendency  is  progressive  from 
first  to  last.    The  general  health  is  but  seldom  affected. 

Treatment 

Of  treatment  in  the  ordinary  sense,  with  a  view  of  a  cure,  there  is 
none.  The  management  comprises,  in  a  general  way,  that  of  eczema, 
psoriasis,  and  ichthyosis.  Alkaline  baths,  subsequent  inunctions,  and 
salicylic  acid  ointment  tend  to  remove  the  overproduction  of  corneous 
matter  and  hence  to  check  the  inflammation.  This  must  be  persisted 
in,  and  thus  conditions  are  made  favorable  for  improvement  and 
recovery. 

Fig.  35.     Model  of  Dr.  Bayet  in  Brussels. 
48 


Plate  24. 


Fig.  36.  liczema  acutuni  cum 
pigmentatioue. 


i  ig.  37.   liczema  folliculare. 


Plate  25. 


/ 


Plate  26. 


X 

05 


03 
E 

(U 
IM 
U 

d 


CQ 

s 
e 

5 


U5 

3 


N 
U 

tu 

CO 


Plate  27. 


Fig.  41.   Lczema  orbiculare  oris. 


Fig.  42.  Eczema  e  prolessioiie. 


Plate  28. 


Fig.  43.  Eczema  chronicum  squamosum. 


Fig.  44.  Eczema  chronicum  corneum. 


Plate  29. 


3 


o 
E 

3 
o 

c 
o 

u 

J3 


<u 

N 
O 

LU 
O 


Eczema 

Plates  24  to  29,  Figs.  36  to  46 

The  conception  of  eczema  has  constantly  undergone  changes,  some 
of  them  radical,  since  the  terra  was  lirst  introduced  by  the  Greeks. 
The  "boiling  over,"  which  the  word  signifies,  does  not  refer  to  the 
discharge  of  moist  eczema,  but  to  hot,  burning  pustules  appearing 
over  the  entire  surface — in  other  words,  furunculosis.  Eczema  meant 
nothing  else  until  the  time  of  Willan,  who  applied  the  term  to  cer- 
tain forms  of  dermatitis  due  to  known  irritants,  characterized  by 
minute  vesicles  or  vesicopustules,  closely  aggregated  and  diffused 
over  the  irritated  area.  Thus  far  there  was  no  suggestion  of  any- 
thing but  an  acute  affection.  Biett,  and  especially  Bayer,  isolated 
vesicular  eczema  from  the  artificial  eruptions,  and  incidentally  estab- 
lished the  fact  that  the  former  could  represent  a  chronic  condition ; 
that  it  was  not  rare  but  extremely  common,  and  that  itching  was 
characteristic — an  itching  vesicular  eruption,  running  chiefly  a 
chronic  course.  Bayer  also  regarded  the  affection  of  the  face  and 
scalp,  previously  known  as  milk  crust,  as  an  acute  phase  of  eczema. 
After  an  interval  of  great  confusion,  Devergie  made  another  advance 
by  retiring  the  vesicle  as  a  characteristic  lesion.  The  most  essential 
phenomena  for  him  were  redness,  a  discharge  which  stains  and 
stiffens  linen,  and  violent  itching.  Hehra  was  the  first  to  insist  that 
eczema  may  never  reach  the  weeping  stage,  and  may  exhibit  only 
diffuse  redness  and  desquamation  or  dry  papulation.  He  isolated 
five  clinical  types — squamous,  papular,  vesicular,  the  red  weeping 
type  (eczema  rubrum  or  madidans),  and  impetigenous  eczema.  This 
conception  of  eczema  has  not  been  radically  changed  since,  but  it  be- 
came apparent  in  time  that  there  were  primary  forms — erythematous, 
papular,  vesicular,  and  pustular — and  secondary  forms — eczema 
rubrum  and  eczema  squamosum.  The  condition  known  as  eczema 
seborrhoicum,  added  by  Unna  to  the  basic  forms  of  the  disease,  is 
considered  elsewhere. 

Eczema  is  a  superficial  inflammation  of  the  skin,  and  the  claim  is 
made  that  all  its  manifestations  may  bo  produced  experimentally,  by 

49 


local  irritation;  while  it  may  exceptionally  pursue  an  acute  course, 
or  occur  in  mild  and  abortive  forms,  it  is  essentially  a  chronic  affec- 
tion; while  it  may  remain  localized  in  the  area  originally  involved, 
its  natural  tendency  is  to  spread ;  the  one  most  characteristic  feature 
is  violent  itching,  with  more  or  less  .burning ;  it  is  non-contagious ;  it 
never  induces  scarring ;  it  exhibits  primary  and  secondary  phases,  or, 
as  some  would  call  them,  initial  and  mature  phases.  It  occurs  in  any 
area  of  the  integument,  and  its  manifestations  vary  greatly  with  the 
locality  involved  and  the  degree  and  extent  of  the  process.  Different 
lesions  may  occur  in  the  same  subject,  and  everything  makes_for 
polymorphism. 

Once  looked  upon  as  a  rare  affection,  eczema  is  now  by  far  the 
most  frequent  of  all  dermatoses.  Wliether  the  present  conception  of 
it  will  stand  is  uncertain.  The  term  "the  eczemas,"  representing  a 
great  group  disease,  would  in  some  ways  be  preferable  to  "eczema." 
It  could  then  include  dermatitis  and  possibly  other  affections. 

Etiology 

Eczema  is  produced  preeminently  by  a  coincidence  of  predispos- 
ing and  exciting  factors.  If  it  could  be  explained  by  the  action  of  the 
latter  "wdthout  the  element  of  predisposition,  we  should  then  rank  it 
as  a  dermatitis  or  perhaps  a  parasitic  disease.  If  there  is  no  evi- 
dence of  any  external  irritant  we  may  assume  the  existence  of  some 
ultramicroscopic  germ,  or  that  some  acute  metabolic  or  other  auto- 
toxic  disorder  acts  as  an  exciting  cause.  Both  exciting  and  predis- 
posing factors  may  escape  us;  but  in  very  many  cases  the  etiology 
is  evident  enough.  These  form  a  connecting  link  between  eczema  and 
dermatitis.  Here  we  see  a  single  exciting  cause  able  to  set  up,  in 
the  absence  of  any  marked  predisposition,  a  condition  which  behaves 
clinically  as  an  eczema.  With  the  removal  of  the  exciting  cause, 
there  shoiild  be  a  tendency  to  recover  permanently,  although  the  con- 
dition would  perhaps  require  further  treatment.  When  the  evidence 
of  a  predisposition  is  apparent,  despite  the  presence  of  an  original 
exciting  cause,  as  shown  by  a  tendency  to  spread  or  to  relapse  spon- 
taneously, we  are  forced  to  assume  the  existence  of  a  diathesis.  In 
earlier  times  it  was  customary,  at  least  in  France,  to  accuse  various 
diatheses,  and  it  is  interesting  to  note  that  the  idea  of  diathesis  in 
this  connection  has  recently  been  revived  in  Germany,  where  it  was 
originally  reviled.  If  we  assume  with  Unna  and  others  that  a  bacte- 
rial factor  must  invariably  bo  present,  then  the  term  diathesis  would 
simply  mean  the  sum  of  all  the  conditions  which  tend  to  make  the  skin 
a  good  culture  medium.    It  is  the  relative  preponderance  of  predis- 

50 


posing  overexciting  causes,  or  the  converse,  which  makes  nearly  every 
case  of  eczema  a  law  to  itself,  and  which  tends  to  the  formation  of  a 
great  number  of  clinical  types,  which  may  differ  as  much  among 
themselves  as  if  they  were  quite  distinct  diseases. 

In  England,  where  gout  is  prevalent,  * 'gouty"  eczema  appears  to 
be  common  and  easily  recognized.  To  call  an  eczema  gouty,  how- 
ever, does  not  mean,  as  Unna  implies,  that  it  must  be  set  up  by  the 
irritation  of  uric  acid  crystals.  A  predisposition  and  an  excitation 
may  both  come  about  from  defective  metabolism.  This  is  seen  dis- 
tinctly in  the  genital  eczema  of  diabetics,  in  which  the  irritating  urine 
promptly  sets  up  vulval  eczema,  which  is  invited  by  the  abnormal 
metabolism  of  the  patient. 

All  the  kno^\^l  metabolic  affections  favor  the  development  of 
eczema;  and  while  these  may  occur  at  any  age,  they  are  practically 
inevitable  in  advanced  years,  and  are  very  largely  sufficient  in  them- 
selves to  explain  eczema  at  that  period  of  life,  which  may,  of  course, 
come  about  prematurely. 

Equally  striking  is  the  relationship  between  the  diet  and  diges- 
tive organs  and  the  peculiar  types  of  eczema  in  the  nursling,  which 
affect  chiefly  the  face  and  scalp  with  a  moist,  crusting  process.  It 
has  long  been  noted  that  babies  with  this  type  of  eczema,  although 
they  may  feed  heartily,  do  not  vomit  or  regurgitate.  Countless  cases 
of  eczema  in  infants  can  be  traced  to  the  custom  of  drinking  beer 
freely  by  their  nursing  mothers,  and  they  generally  recover  as  soon 
as  the  mother's  diet  is  supervised.  So  slight  a  correction  of  the  diet 
of  a  bottle-fed  baby  as  lengthening  the  interval  between  feedings  has 
frequently  been  followed  by  very  decided  improvement  even  in  severe 
cases. 

In  certain  local  types  of  eczema,  the  dependence  on  a  single  clean- 
cut  cause,  whether  we  term  this  predisposing  or  exciting,  is  marked 
— so  much  so  that  we  hesitate  about  calling  it  eczema.  Here  belong 
the  various  eczemas  of  the  legs  and  scrotum,  the  orificial  eczemas  due 
to  irritating  secretions,  especially  those  of  the  upper  lip,  nipples,  and 
genitals,  the  intertriginous  eczemas,  etc.  Like  the  professional  ecze- 
mas so-callod,  all  these  appear  to  form  a  link  between  dermatitis  and 
the  purest  forms  of  eczema. 

Another  point  of  contact  between  eczema  and  dermatitis  of  me- 
chanical cause  is  very  often  conspicuous.  In  certain  types  of  eczema 
tlie  itching  is  by  far  the  most  prominent  sjTiiptom.  The  actual  lesions 
are  barely  evident  as  minute  papules  or  even  a  mere  redness,  repre- 
senting abortive  forms.    As  a  result  of  the  itching,  the  great  major- 

61 


ity  of  the  lesions  are  artefacts,  produced  by  scratching,  rubbing,  etc. 
The  extensive  hypertrophic  thickening  of  the  skin  in  some  cases  of 
clironic  eczema  may  be  due  very  largely  to  habitual  irritation.  So 
notable  is  the  tendency  to  scratch  in  eczema  that  it  is  often  difficult 
to  get  an  idea  of  the  actual  lesions  of  the  disease.  Many  are  of  the 
opinion  that  if  scratching  could  be  prevented  at  the  outset  eczema 
would  be  a  disease  of  trifling  lesions  only. 

Many  cases  of  eczema  occur  under  such  circumstances  of  loca- 
tion and  form,  that,  in  the  total  absence  of  predisposing  or  exciting 
factors,  we  can  think  only  of  a  parasitic  origin.  Here  belongs  espe- 
cially the  nummular  eczema  on  the  backs  of  the  hands,  fingers,  fore- 
arms, etc.  The  parasitic  origin  is  even  more  plausible  in  so-called 
seborrheic  eczema,  which  is  seen  especially  on  the  scalp,  face,  ster- 
num, intrascapular  region,  etc.,  and  which  exceptionally  occurs  any- 
where on  the  surface.  The  appearance  and  mode  of  spreading  of  all 
these  lesions  suggests  a  parasitic  cause. 

An  eczema  varies  considerably  in  its  lesions  according  to  locality. 
On  hairy  regions  it  is  much  more  inclined  to  form  pus  than  on  smooth 
ones,  because  infection  with  pyogenic  germs  comes  about  with  greater 
certainty.  In  folds  eczema  has  a  greater  tendency  to  become  moist 
than  elsewhere,  although  the  worst  tj'pes  of  weeping  eczema  occur 
quite  independently  of  location.  Eczema  of  the  palms  and  soles  is 
naturally  attended  by  much  more  thickening  of  the  epidermal  layers 
than  in  other  localities.  "When  eczema  occurs  in  the  rosacea  area 
of  the  face  it  is  often  difficult  to  distinguish  it  from  the  latter  affec- 
tion. 

Acute  erythematous  eczema  of  the  face  may  cause  an  unusual 
amount  of  swelling,  the  eyelids  becoming  so  edematous  that  they  can- 
not be  opened. 

Diagnosis 

Enough  has  already  been  said  of  the  characteristic  features  of 
eczema,  and  it  only  remains  to  give  the  differential  diagnosis.  To 
discriminate  between  acute  eczema  of  the  face  and  erysipelas  is  a 
matter  of  vital  importance,  for  it  no  doubt  happens  at  times  that 
patients  with  the  former  are  isolated  and  treated  as  very  sick  individ- 
uals. The  patient  mth  eczema  is  never  affected  constitutionally, 
although  very  young  children  may  present  some  malaise  and  tem- 
perature. He  has  no  toxemia,  no  fever  or  prostration.  His  face  may 
resemble  greatly  the  erysipelas  mask,  but  the  swelling  is  not  brawny 
nor  is  the  contour  sharp  and  indented.  In  eczema  the  color  shades 
gradually  into  the  normal  tint. 

52 


Dry  squamous  eczema  may  greatly  resemble  psoriasis,  but  the 
proper  diagnosis  should  be  made  in  any  doubtful  case  after  a  proper 
amoimt  of  observation. 

WTiat  is  true  of  psoriasis  applies  to  some  extent  to  lichen  planus. 
When  the  patches  first  appear  they  may  closely  resemble  eczema. 
Study  of  the  case  will  probably  lead  sooner  or  later  to  tlie  recognition 
of  the  peculiar  primary  lesion  of  lichen,  the  triangular  dellated 
papule ;  .just  as  in  psoriasis,  the  minute  papule  with  its  disproportion- 
ately thick  crust  will  reveal  that  affection.  Pustular  eczema  is  readily 
confounded  with  other  pustular  eruptions,  but  as  far  as  the  secondary 
pyogenic  infection  is  concerned  it  is  practically  the  same  condition 
throi;ghout,  demanding  much  the  same  management. 

Two  such  multiform  affectidiis  as  syphilis  and  eczema  nmst  at 
w  times  Simula  1 1'  farli  oilier.  Squamous  eczema  sometimes  bears  con- 
^^'^  siderable  reseniblanee  to  i)apulosquamous  syphilides,  and  palmar  and 
plantar  S5i)hilides  may  simulate  eczema.  The  differential  tests  are 
the  presence  or  absence  of  history  of  syphilis  and  vestiges  of  this 
affection,  the  presence  or  absence  of  itching  (the  only  sypliilidc  which 
itches  at  time? is  the  generaEzed  ga^ular  eruption,  a  coiniiaratively 

VlaTe  secondary  phenomenon) ,~a"n3r finally  tlie  elTc  .t  ot  anti-sypliilitic 
treatment.  The  prefungoid  eruption  in  granuloma  fungoides  is  often 
indistinguishable  from  a  chronic  eczema. 


Treatment 

If  there  is  any  evidence  of  faulty  metabolism  or  any  derangement 
of  the  digestive  apparatus,  or  if  the  diet  of  the  patient  is  badly  chosen, 
he  will  not  be  likely  to  recover  unless  these  conditions  are  first  cor- 
rected. It  is  a  common  experience  that  not  only  eczema  but  nimierous 
other  dermatoses,  such  as  all  forms  of  seborrhea  and  acne,  pruritus, 
chronic  urticaria,  etc.,  tend  to  improve,  and  become  aggravated  under 
much  the  same  conditions  of  general  nutrition,  digestion  and  diet. 
The  same  individual  may  present  a  number  of  these  affections  at  the 
same  time  or  in  succession.  Placed  upon  a  restricted  diet  and  general 
hygienic  regimen  of  exercise,  hydrotherapy,  etc.,  all  these  conditions 
show  a  common  tendency  to  improve.  Some  connection  is  often 
apparent  between  these  dermatoses  and  overweight.  As  the  subject's 
weight  is  reduced  by  his  regimen  the  resistance  of  the  skin  increases. 
This  general  therapeutic  indication  must  always  be  borne  in  mind  in 
the  management  of  eczema.  The  predisposition  herein  implied  is  not 
deep-seated  enough  to  be  termed  an  inborn  diatliesis,  but  simply  the 
result  of  malhygiene  and  hence  preventable.    Even  the  deep-seated 

68 


■^ 


metabolic  anomalies  of  actual  or  premature  senility  are  not  neces- 
sarily diathetic  but  are  due  chiefly  to  the  fact  that  with  advancing 
years  the  subject  continues  to  eat  heartily  while  exercising  progres- 
sively less.  The  nutrition  in  all  these  subjects  has  become  so  de- 
ranged that  the  skin  may  become  a  culture  medium  for  ordinary 
pathogenic  cocci  and  even  for  others  which  ordinarily  are  harmless 
saprophytes. 

The  limits  of  this  article  do  not  afford  scope  for  a  consideration  of 
the  general  management  of  eczema,  but  under  etiology  the  various 
causal  factors  were  considered.  In  regard  to  the  subject  of  inter- 
nal medication  in  eczema,  certain  remedies  are  no  doubt  highly  bene- 
ficial, although  the  rationale  may  not  be  clear.  In  any  case  of  acute 
generalized  eczema  or  acute  eczema  of  the  face  large  doses  of  acetate 
of  potassium  have  been  used  with  success  for  over  a  century. 

The  belief  formerly  prevailed  that  acute  eczema  of  internal  causa- 
tion was  dependent  in  some  way  on  acute  renal  insufficiency,  the  urine 
being  commonly  concentrated.  The  diuretic  action  of  the  potash  ap- 
peared to  be  succeeded  by  a  rapid  retrogression  of  the  eruption.  It 
has  been  pointed  out  that  in  renal  disease  we  naturally  stimulate  the 
skin,  and  that  the  opposite  course  is  rational  when  conditions  are 
reversed.  The  extreme  swelling  of  the  eyelids  in  acute  eczema 
of  the  face  certainly  appears  to  yield  promptly  to  the  action  of 
diuretics. 

The  action  of  arsenic  on  chronic  eczema  is  unmistakable  and_it  is 
often  use^  hypbdeVhlicallylo  secure  prompt  results. 

Internal  remedies — sedatives  and  hypnotics — have  some  influence 
over  the  itching,  enough  to  aid  the  patient  in  getting  his  sleep.  Gel- 
semium  has  been  recommended  in  desperate  cases.  More  recently  the 
various  synthetic  analgesics — phenacetin,  antipyrin,  etc. — have  been 
used  for  this  purpose. 

Locally,  the  principal  indication  is  to  subdue  the  itching,  for  in 
many  cases  this  represents  almost  the  whole  of  the  disease,  the  lesions 
being  principally  those  arising  from  constant  scratching  and  rubbing. 
It  is  never  advisable  to  dissuade  the  patient  from  scratching,  as  this 
is  often  beyond  his  power.  No  one  substance  has  any  constant  superi- 
ority as  an  antipriiritic.  Phenol,  menthol,  chloral,  camphor,  corrosive 
sublimate  are  some  of  the  more  powerful  remedies  used,  but  milder 
substances,  like  boric  and  salicylic  acid  and  thymol,  may  be  sub- 
stituted. 

In  acute  eczema  the  antipruritic  may  be  combined  with  anti- 
phlogistic remedies  when  these  are  indicated.    The  ointment  or  the 


sodimont  in  tlio  lotions  also  serves  the  purpose  of  excluding  the 
air,  which  intensifies  the  itching.  The  substances  used  to  form  the 
sediment  are  usually  zinc  or  bismuth  compounds,  which  have  an  anti- 
phlogistic action,  and  are  also  added  to  the  ointments.  A  good  oint- 
ment may  be  made  wth  cold  cream  as  a  base  and  should  contain 
calamine,  zinc  oxide  or  bismuth  subnitrate  with  the  addition  of  phe- 
nol, menthol  or  camphor.  A  corresponding  lotion  should  have  as  a 
vehicle  weak  lime  water,  and  contain  the  same  ingredients.  Oint- 
ments give  the  best  results  when  they  can  be  applied  with  a  fixed 
dressing,  but  lotions  are  preferred  for  all  exposed  localities  for  their 
cosmetic  possibilities.  Whenever  the  inflammatory  reaction  is  con- 
siderable, ichthyol  is  indicated,  and  in  some  cases  may  be  combined 
with  the  remedies  already  mentioned. 

Most  acute  cases  should  recover  promptly  if  the  dressiogs  could 
be  made  permanent  and  changed  only  once  a  day.  In  practice,  how- 
ever, this  is  seldom  practicable,  as  patients  do  not  wish  to  be  inval- 
ided. Hence  a  compromise  treatment  must  be  devised.  The  patient 
must  forego  washing  his  skin  or  disturbing  it  in  any  way,  excepting 
with  a  special  technique.  Since  ointments  cannot  be  used  freely  in 
ambulatory  cases  during  the  day,  it  is  the  custom  to  use  lotions  at  that 
period  and  ointments  at  night.  This  necessitates  removing  the  oint- 
ment in  the  morning,  which  is  done  preferably  with  suds  of  tar 
soap.  The  skin  is  then  dried  by  simply  blotting  it  with  gauze  and 
the  lotion  applied  thickly.  If  the  locality  is  such  that  the  sediment 
wears  away  it  must  be  repeated  over  and  over.  The  parts  are  thus 
kept  constantly  protected  from  the  air  and  in  contact  w'ith  antipruritic 
and  sedative  substances. 

If  a  large  area  of  integument  is  involved,  the  patient  should  take 
a  medicated  bath  on  retiring,  A  pound  each  of  starch  and  soda  may 
be  placed  in  the  bathtub  and  allowed  to  dry  upon  the  skin  of  the  pa- 
tient. If  the  surface  involved  is  large,  ointments  and  lotions  cannot 
be  applied  thickly.  A  thin  layer  of  carbolized  vaseline  will  answer, 
for  the  skin  has  already  received  a  coating  of  soda  and  starch. 

Dusting  powders  are  also  serviceable  when  there  is  a  large  area  of 
skin  involved,  and  they  may  also  be  applied  over  the  lotions.  They 
may  be  applied  in  all  exudative  cases,  but  possess  no  advantage  over 
sediment  lotions  made  with  the  same  substances  save  for  the  extreme 
facility  with  which  they  may  be  applied.  They  are  useful  in  hospital 
and  dispensary  practice. 

^Vhile  ointments  cannot  well  be  used  over  weeping  surfaces  in  the 
ordinary  state,  they  may  be  combined  with  starch,  casein,  zinc  oxide, 

65 


etc.,  in  special  percentages — generally  equal  parts  of  vaseline  and 
powder.  If  these  pastes  so-called  are  applied  firmly  with  fixed  dress- 
ings, the  fluid  is  absorbed. 


Fig.  36.    Model  in  Neisser's  Clinic  in  Breslau  (Kroener). 

Fig.  37.    Model  in  Freiburg  Clinic  {Johnsen). 

Fig.  38.     Model  in  Freiburg  Clinic  (Voffelbaclier). 

Fig.  39.    Model  in  Polyclinic  of  Prof.  M.  Joseph  in  Berlin  {Kolbotc). 

Fig.  40.  ]\IodeI  in  Freiburg  Clinic  {Jolmsen).  Weeping  and  scabbing 
eczema  of  the  armpits  in  a  very  fat,  sweaty  man,  in  whom  the  genitals 
and  surrounding  parts,  the  anal  and  the  umbilical  regions  were  also 
eczematous. 

Fig.  41.    Model  in  St.  Louis  Hospital  in  Paris,  No.  295  (Baretta). 

LaiUer's  case. 

Fig.  42.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

Fig.  43.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener) . 

Fig.  44.     Model  in  St.  Louis  Hospital  in  Paris,  No.  591    {Buret ta). 

Foumier's  case. 

Fig.  45.     Model  in  Freiburg  Clinic  {Johnsen). 

Fig.  46.     Model  in  St.  Louis  Hospital  in  Paris,  No.  770  {Baretta) 

Foumier's  case. 

56 


Plate  30. 


Fig.  47.  48.  Prurigo. 


Prurigo 

Plate  30,  Figs.  47  and  48 

This  affection  is  comparatively  rare  in  the  United  States  and  the 
cases  encountered  are  generally  observed  in  iimnigrants  from  Central 
I'^urope.  All  attempts  to  connect  it  nostologically  with  papular  and 
itching  affections  seen  in  this  country  are  futile.  Wliile  it  may  occur 
sporadically  in  the  very  poor  and  desolate  in  any  country,  this  fact  in 
no  wise  accounts  for  its  cumulation  in  Austria-Hungary. 

While  prurigo  may  begin  with  the  simple  itching  of  an  intact  skin, 
or  one  with  urticaria  papulosa,  the  most  intense  and  persistent 
scratching  in  other  dermatoses  does  not  commonly  transform  them 
into  true  prurigo.  Even  the  so-called  mild  form  of  the  latter  retains 
its  indi%aduality  and  is  not  chronic  urticaria. 

Prurigo  no  doubt  begins  as  wheals,  especially  in  nurslings,  and 
to  a  progressively  less  extent  as  the  age  increases.  Cases  are  now 
alleged  to  begin  in  adults.  Adhering  chiefly  to  the  original  descrip- 
tion of  the  Vienna  dermatologists,  it  persists  until  the  early  part  of 
the  second  year  as  a  mere  association  of  urticarial  papules  and 
wheals  and  scratch  marks.  These  are  at  once  supplanted  by  papules 
which  are  of  the  color  of  normal  integument  and  represent  inflanmia- 
tory  formations.  The  latter  no  doubt  represent  old  urticarial  pap- 
ules. In  the  meantime  itching  reaches  a  maximum,  so  that  sleeping 
becomes  difficult.  A  scratch  dermatitis  develops,  but  not  in  excess 
of  what  may  be  seen  in  other  pruriginous  dermatoses.  The  prurigo 
papules  are  not  of  this  origin,  although  doubtless  intensified  thereby. 

The  disease  may  reach  an  acme  of  severity  before  the  third  year 
is  passed.  The  papules  occupy  chiefly  the  exterior  surfaces  of  the 
extremities,  especially  the  lower.  The  ocular  appearance  is  some- 
times deceptive,  so  that  the  sense  of  touch  is  indispensable  for  diag- 
nosis. The  lesions  project  slightly  above  the  skin  level,  so  that  a 
papule  very  often  exhibits  a  dot  of  dried  blood  on  its  summit  from 
scratching.  Trophic  disturbances  seem  in  evidence,  as  the  skin  is 
unnaturally  dry  and  rough,  the  hair  dry,  etc.    Further  changes  due 

67 


to  protracted  scratching  are  thickening  of  the  skin,  pigmentation,  and 
at  times  areas  of  simple  dermatitis  not  comiected  with  the  disease. 
One  of  the  most  characteristic  symptoms  is  the  chronic  inguinal  bubo 
commonly  present  in  fully  developed  cases.  Patients  with  chronic 
prurigo  generally  show  failure  of  nutrition. 

Etiology 

Age  has  already  been  mentioned.  Prurigo  is  never  inlierited, 
never  congenital.  Some  familial  predisposition  is  seen  at  times. 
There  seems  no  doubt  that  it  develops  on  an  urticarial  basis.  As  a 
rule  urticaria  of  childliood  has  no  sequelae,  and  even  the  worst  cases 
of  prurigo  are  sometimes  outgrown  at  an  early  period.  The  unknown 
X  is  involved  in  the  problem  of  the  transition  of  an  urticaria  into 
prurigo.  The  evidence  of  a  dystrophic  skin  as  the  cause  is  not  suffi- 
cient, and  at  present  we  have  no  clue  to  this  factor. 

Diagnosis 

This  is  made  first  by  the  location  and  history  of  early  develop- 
ment ;  the  characteristic  papules  and  inguinal  buboes ;  the  dry  skin ; 
and  further  by  exclusion  of  eczema  (especially  in  a  dry  skin) ;  para- 
sitic diseases  and  other  forms  of  itching  affections. 

Prognosis 

This  should  be  guarded  as  to  the  duration  of  the  disease. 

Treatment 

Hygienic  and  nutritive  management  represents  the  first  line  of 
treatment.  A  course  of  quiet  with  liberal  feeding  is  rationally 
indicated.  Pilocarpin  antagonizes  the  dry  skin.  The  itching  and 
irritation  require  warm  alkaline  baths,  followed  by  inunctions  with 
ointments  containing  phenol,  naphthol,  tar,  etc. 


Figs.  47  and  48.     Models  in  Neisser's  Clinic  in  Breslau  (Kroener). 

.58 


Plate  31. 


Fig.  4Q.  Lichen  planus. 


Fig.  50.   Lichen  planus  atiophicus. 


Plate  32. 


Fig.  51.  Lichen  planus  verrucosus. 


Plate  33. 


3 


C 


en 


bfi 


re 
3 


3 

c 


in 


to 


Lichen  Planus 

Plate  31,  Figs.  49  and  50;  Plate  32,  Fig.  51;  Plate  33, 
Figs.  52  and  53 

This  is  a  unique  affection,  the  characteristic  lesion  of  which  is  a 
small  papule,  flat  and  triangular  or  polyhedral,  having  a  minute 
central  depression ;  the  color  is  deep  red  or  livid  and  a  peculiar  waxy 
lustre  is  evident.  These  papules,  naturally  isolated,  readily  coalesce 
to  form  patches  and  sometimes  rings.  In  a  patch  it  is  usually  possi- 
ble to  recognize  the  original  papules,  whose  borders  and  depressions 
still  persist.  The  patches  show  a  slight  degree  of  sealing.  As  a  rule 
the  papules  are  extremely  persistent  and  are  liable  to  come  out  in 
successive  crops.  There  is  some  tendency  to  pale  out  and  undergo  a 
sort  of  atrophy.  The  typical  papule  is  less  than  an  eighth  of  an  inch 
in  diameter.    In  some  subjects  they  leave  deep  pigmentation. 

The  disease  is  naturally  disposed  to  a  general  distribution  but  has 
certain  areas  of  preference  as  the  flexor  surface  of  the  forearms  and 
lower  portion  of  the  legs.  The  papules  are  sparsely  distributed  at 
first  and  later  become  more  dense,  but  do  not  tend  to  appear  at  the 
outset  in  isolated  groups.  Exceptions  occur,  however.  As  already 
stated  small  rings  of  papules  sometimes  form  or  the  latter  may  be 
arranged  in  chains.  When  the  disease  attacks  the  glans  and  foreskin 
or  the  inside  of  the  cheeks,  the  papules  appear  closelj'  grouped  and 
in  fact  may  be  confined  to  one  or  both  of  these  situations.  Exception- 
ally they  are  seen  on  the  female  genitals,  and  the  tongue.  On  all 
these  mucous  surfaces  the  papules  have  a  whitish  appearance,  save 
in  persons  with  exposed  glans  where  the  eruption  resembles  that  on 
the  skin. 

Lichen  often  assumes  a  chronic  form  and  presents  a  notable  degree 
of  itching,  so  that  the  effects  of  prolonged  scratching  are  sometimes 
apparent. 

Etiology 

The  causation  of  lichen  planus  is  still  a  matter  of  conjecture.  It 
is  generally  regarded  as  being  dependent  on  some  form  of  nerve  dis- 
order, and  in  patients  presenting  acute  general  eruptions,  with  intense 
pruritus,  it  is  seldom  difficult  to  obtain  evidence  tending  to  support 
this  theory.  They  are  often  either  apprehensive  or  depressed,  and 
the  history  of  recent  shock  or  fright  is  occasionally  obtained.    LUce 

59 


many  another  affection,  lichen  planus  often  develops  in  subjects 
whose  resistance  has  been  diminished  by  poor  nutrition,  overwork 
and  nervous  insufficiency,  but  there  seems  to  be  no  warrant  for  mak- 
ing it  a  neurosis.  It  may  occur  in  young  and  apparently  vigorous 
subjects.  Some  authorities  now  regard  the  disease  as  an  infective 
granuloma.  The  lesions  appear  to  represent  an  inflammatory  infiltra- 
tion in  the  outer  portion  of  the  corium,  involving  some  thickening  of 
the  rete  and  horny  layer,  and  hypertrophy  of  the  papillae. 

Diagnosis 

Wliile  numerous  other  affections  produce  papules  none  of  these 
resembles  in  the  slightest  the  lesion  of  lichen  planus.  Once  seen,  the 
latter  could  hardly  be  forgotten.  Wlien,  however,  the  lesions  become 
grouped,  the  patches  readily  simulate  chronic  squamous  affections. 
This  is  especially  prone  to  occiar  when  large  patches  are  formed  in 
some  unusual  locality,  as  over  the  knees.  Lichen  may  also  show  a 
special  tendency  to  form  multiple  scaling  patches.  When  rings  are 
formed  showing  various  stages  of  development  it  may  be  necessary 
to  exclude  the  other  ringed  affections,  as  syphilis,  ringworm,  etc. 
Confusion  with  lichen  ruber  of  Hehra  is  doubtless  due  to  the  fact  that 
atypical  forms  of  each  may  simulate  the  other.  Typical  cases  show 
no  parallelism. 

Prognosis 

The  affection  is  naturally  chronic  and  sometimes  progressive.  In 
many  cases,  however,  there  seems  to  be  a  natural  tendency  to  recov- 
ery.  With  proper  treatment  the  outlook  for  recovery  is  always  good. 

Treatment 

This  is  influenced  largely  by  the  stage  of  the  disease  and  the  type 
of  eruption  presented.  In  the  acute  hyperemic,  disseminated  variety 
the  internal  treatment  should  at  first  consist  only  of  alkaline  mix- 
tures.   The  following  are  good  examples : 

IJ  Potassii  citrat 3vl 

Tr.  nucis  vomicae 5ii 

Aqui-E ad  'iii 

M.  et  ft.     Sig. — Teaspoonful  in  water  after  meals. 

1^  Potassii  acetat oiii 

Potassii   bicarbonat 3iii 

Tinct.  gent,  comp 3vi 

Syr.  auranti  dulc 5' 

AqusB ad  3'ii 

M.  et  ft.     Sig. — Teaspoonful  in  water  after  meals. 

60 


Mild  laxativos  are  also  indicated,  the  diet  should  be  restricted  and 
alcoliol  prohibited.  The  discontinuance  of  tobacco  is  not  always 
advisable,  as  it  often  seems  to  increase  the  nervous  irritability.  As 
soon  as  the  acute  stage  begins  to  subside,  mercurial  treatment  should 
be  instituted,  for  there  is  now  but  little  doubt  as  to  the  superiority  of 
mercury  over  all  other  drugs  in  the  treatment  of  this  disease.  In 
many  cases  its  effect  is  almost  specific.  The  results,  however,  are  not 
always  uniform.  It  should  be  administered  in  increasing  doses  until 
either  improvement  in  the  eruption  occurs,  or  beginning  mercurial- 
ism  is  noticed.  A  fairly  accurate  method  of  administration  is  in  the 
form  of  one-grain  tablets  of  hydrargynmi  cum  creta.  From  six  to 
twelve  of  these  may  be  taken  daily,  according  to  the  effect  produced. 
Mercury  can  also  be  advantageously  given  in  the  form  of  bichloride, 
Hz  to  H2  of  a  grain  three  times  a  day.  This  is  best  given  in  a 
mixture,  but  in  certain  selected  cases  it  may  be  administered 
intravenously. 

Should  the  treatment  with  mercury  be  unsatisfactory,  recourse 
may  be  had  to  arsenic,  which  must  also  be  given  in  full  doses,  but 
never  in  the  acute  stage.  It  can  be  administered  in  the  form  of 
Fowler's  or  Pearson's  solutions,  in  doses  of  from  five  to  twelve 
minims  three  times  per  day.  A  more  convenient  method  of  adminis- 
tering arsenic  is  in  the  form  of  tablets  or  pills.  A  tablet  containing 
^^0  of  a  grain  of  sodium  arseniate  may  be  taken  after  each  meal,  and 
the  dose  increased  by  one  every  three  days  until  three  are  taken  after 
each  meal,  then  return  is  made  to  the  first  dosage.  Occasionally  the 
Asiatic  pill,  which  contains  Ho  of  a  grain  of  arsenious  acid,  is  useful. 
Intramuscular  injections  of  cacodylate  of  sodium  have  been  recom- 
mended, and  recently  there  have  been  a  few  favorable  reports  from 
the  use  of  salvarsan  intravenously  administered. 

In  acute  cases,  where  arsenic  is  contraindicated,  Pringle  recom- 
mends the  wine  of  antimony  in  fifteen-minim  doses,  three  times  a  day. 
The  same  writer  has  reported  rapid  subsidence  of  inflammation  and 
complete  cessation  of  itching  in  an  acute  case  after  the  use  of  antipy- 
rin  in  ten-grain  doses  given  three  times  a  day.  Bulkley  uses  chlorate 
of  potassa,  five  to  ten  grains  in  water,  after  meals,  followed  half  an 
hour  later  by  two  to  five  drops  of  strong  nitric  acid,  well  diluted. 
Eartzell  has  had  favorable  results  from  the  salicylate  of  soda.  Con- 
stitutional treatment  should  be  continued  for  some  time  after  the 
eruption  has  disappeared.  The  nervous  exhaustion  that  not  infre- 
quently follows  a  severe  attack  of  lichen  planus  is  best  overcome  by 
the  use  of  strychnine.  Tablets  of  strychnia  nitrate  of  Ho  of  a  grain 
may  be  given  three  times  a  day.    The  glycerophosphates  of  lime  and 

61 


soda  are  also  useful,  and  the  following  formula,  in  which  they  are 
combined  with  strychnia,  is  an  excellent  one: 

IJ  Strychnia  nitrat gr.  %4 

Calcii  glyceropliosph., 

Sodii   glyceropliosph aa  gr.  iiss. 

M.  et  ft.  cap.    Sig. — One  capsule  three  times  a  day  before  meals. 

Local  treatment  in  the  acute  stage  should  be  soothing,  and  consists 
in  the  main  of  cooling  lotions,  such  as  the  calamine  and  zinc  lotion,  or : 

IJ  Pulv.  boracis    oii 

Tr.  camphoras    3iii 

Glycerine 3ii 

Aquas  aurantii  florum    ad  §viii 

M.  et  ft.  lotio. 

Alkaline  and  bran  baths  are  cooling  and  generally  grateful. 

As  soon  as  the  acute  symptoms  subside,  mildly  antiseptic  oint- 
ments, such  as  ammoniated  mercury  2i^%  or  salicylic  acid  5%,  can 
be  used.  Tar,  in  the  form  of  lotion,  ointment  or  paste,  is  useful.  In 
the  chronic  type  the  following  ointment,  recommended  by  Unna,  may 
be  applied : 

J^  Hydrargyri    bichlorid gr.  iv 

Acid,    carbolici 9  i 

Ungt.    diachyli §i 

M.  et  ft. 

In  the  hypertrophic,  verrucous  variety,  appearing  most  frequently 
on  the  legs,  the  treatment  should  be  stimulating ;  a  ten  to  twenty  per 
cent,  salicylic  acid  and  rubber  plaster  acts  very  well. 

The  following  collodion  paint  is  also  useful: 

^  Acidi  carbolici gr.  x 

Hydrargyri   bichlorid gr.  iii 

Creosote    HK  iii 

Collodion    §i 

M.  et  ft. 

A  mercurial  plaster  is  sometimes  of  benefit.  In  particularly  in- 
tractable cases  the  X-rays  are  occasionally  of  service. 

Figs.  49  and  52.     Model  in  St.  Louis  Hospital  in  Paris,  Nos.  1398  and 
1554!  {Baretta).     Hallopeau's  case. 

Fig.  50.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

Fig.  51.     Model  in  Freiburg  Clinic  {Vogelbacher). 

Fig.  53.    Model  in  Municipal  Hospital  in  Cologne.    Prof.  Zinsser. 

62 


Plate  34. 


Fig.  54.  Psoriasis  gyrata  et  serpiginosa. 


Plate  35. 


Fig.  55.  Psoriasis  vulgaris  guttata  et  ostracea.  Fig.  56.  Psoriasis  vulgaris. 


Plate  36. 


Fig.  57.  58.  Psoriasis  vulgaris. 


Plate  37. 


« 
o 


o 

o 

CSS 

in 


Plate  38. 


Fig.  61.  Psoriasis  vulgaris  unguium. 


Fig.  62.  Psoriasis  vulgaris  rupioides. 


Psoriasis 

Plate  34,  Fig,  54;  Plate  35,  Figs.  55  and  56;  Plate  36,  Figs.  57  and 
58;  Plate  37,  Figs.  59  and  60;  Plate  38,  Figs.  61  and  62 

This  affection,  because  of  its  characteristic,  scaly,  white  spots,  and 
its  intractable  character,  is  believed  to  have  been  comprised  in  the 
original  conception  of  leprosy,  and  perhaps  to  have  made  up  much  of 
biblical  leprosy.  The  superstitions  which  have  come  down  to  us  at- 
tached to  the  scaliness  of  leprosy  and  the  contagious  nature  of  the 
scabs  are  hardly  reconcilable  with  what  we  know  of  leprosy  to-day. 
On  the  other  hand,  the  affection  known  to  the  Greeks  as  "alphos"  ap- 
plies in  a  measure  to  vitiligo,  a  white  but  not  a  scaly  dermatosis.  The 
very  word  lepra  implies  a  scale,  and  it  must  be  remembered  that  the 
Greek  word  for  true  leprosy  was  elephantiasis.  Psoriasis  may  there- 
fore have  been  the  lepra  of  the  Greeks,  but  this  was  not  true  leprosy. 
The  dissimilarity  between  these  affections  is  very  marked,  and  the 
confusion  is  due  entirely  to  ancient  etymological  misconceptions. 

Psoriasis  in  its  inception  is  a  sharply  individualized  disease.  The 
first  lesion  to  appear  is  a  small  red  papule  the  size  of  a  pin-head  or 
point.  This  is  surmounted  by  a  fine  silvery  scale.  "Wlien  tliis  minute 
scale  is  picked  off  a  hyperemic  base  is  disclosed.  This  has  been  aptly 
termed  the  pathological  unit,  for  from  it  all  the  other  lesions  of  the 
disease  are  derived.  There  is  no  other  dermatosis  whicli,  beginning 
as  a  mere  point  in  the  skin,  presents  at  the  same  time  a  definite  scale. 
After  a  large  area  of  psoriasis  has  once  been  formed  the  scaling  is  not 
so  much  in  evidence.  We  see  a  congested  and  slightly  infiltrated  area, 
surmounted  by  scales,  but  not  differentiated  sharply  from  other  red, 
squamous  affections.  The  spots  with  which  psoriasis  begins  vary 
much  in  size  and  in  thickness  of  scale  with  the  individual  case ;  but 
generally  speaking,  the  size  of  the  scale  is  out  of  all  proportion  to  the 
degree  of  subjacent  disturbance.  A  thick,  adherent  crustlike  scale 
may  be  seated  on  an  area  of  skin  but  slightly  compromised.  Histo- 
logically, as  might  be  expected,  psoriasis  proves  to  be  an  affection  of 

68 


the  epidermis.    Tlie  papillary  layer  of  the  corium  is  only  secondarily 
involved,  from  a  tendency  of  the  rete  to  grow  inward. 

Psoriasis  is  eminently  a  general  dermatosis,  despite  the  fact  that 
it  may  sometimes  be  located  for  the  time  in  narrow  areas.  As  a  rule 
it  appears  widespread,  and  lesions  may  occur  in  any  locality.  As  an 
eminently  disseminated  affection,  it  may  appear  simultaneously  in  a 
number  of  localities,  although  most  prominently  in  some  one  area. 
There  may  be  a  thick  crop  over  the  small  of  the  back  and  buttocks 
with  more  sparse  lesions  elsewhere.  Much  depends  upon  the  course. 
The  more  acute  the  outbreak  the  greater  may  be  the  range  of  localities 
involved.  The  more  chronic,  conversely,  the  more  the  affection  may 
favor  certain  localities — for  example,  the  scalp,  elbows  and  knees. 

In  an  outbreak  of  psoriasis,  as  with  other  dermatoses,  two  ele- 
ments enter.  First,  the  localities  originally  attacked ;  and  second,  the 
course  of  the  affection  in  these  original  localities.  Suppose  the  latter 
to  be  any  one  of  the  favorite  seats  of  the  disease.  There  may  be  no 
spread  of  the  affection  from  the  primary  focus ;  in  fact,  after  a  sta- 
tionary period,  there  may  be  spontaneous  involution.  This,  however, 
is  exceptional.  All  large,  figurate  lesions  in  psoriasis,  wherever  or 
however  produced,  come  about  from  changes  in  elementary  lesions. 
Psoriasis  is  a  disease  naturally  macular  or  maculopapular  in  char- 
acter. The  mere  surface  points  or  droplets  with  which  the  affection 
begins  may  increase  to  the  size  of  a  large  coin,  but  seldom  beyond  this. 
"Whenever  this  or  any  considerable  size  is  reached,  the  patch  tends  to 
clear  up  in  the  centre,  leaving  a  ring ;  while  the  fusion  of  annular  seg- 
ments produces  a  gyrate  pattern.  The  original  nummular  patches 
may  fuse  together,  with  the  production  of  wide,  diffuse  areas.  Psor- 
iasis, then,  begins  as  a  point  and  may  increase  to  the  size  of  a  pea  or 
to  that  of  any  of  the  coins.  At  any  stage  its  growth  may  become 
arrested.  The  individual  lesions  may  be  thickly  grouped,  and  fusion 
may  occur  at  any  stage.  But  at  any  time  one  of  the  larger  lesions 
may  clear  up  in  its  centre,  leaving  a  ring ;  and  coalescence  of  these 
partially  involved  lesions  may  give  rise  to  peculiar  figurate  patterns. 

The  more  rapid  the  evolution  of  a  psoriasis,  the  greater  the  dis- 
semination and  the  less  in  evidence  the  scaling.  Such  cases  suggest 
a  rash,  and  may  even  burn  and  itch.  In  some  cases  it  seems  hardly 
conceivable  that  such  eruptions  are  really  psoriasis.  It  is  of  course 
possible  that  some  ordinary  rash  can  incite  the  appearance  of  a 
psoriasis  in  one  disposed  to  it.  That  local  conditions  shape  the  dis- 
tribution is  well  shoA\Ti  by  the  occasional  appearance  of  the  disease  in 
recent  cuts,  scratches  and  burns. 

64 


In  the  consideration  of  psoriasis,  we  must  know  how  the  affection 
originates ;  for  once  it  is  in  full  evolution  it  can  hardly  be  reduced  to 
sjnnptomatology.  Aside  from  a  few  localities,  like  the  elbows,  knees 
and  scalp,  psoriasis  presents  no  particular  local  types.  It  affects  the 
extensor  more  than  the  flexor  surfaces,  and  usually  spares  the  palms 
and  soles,  save  in  the  generalized  cases.  The  face,  especially  the  more 
central  portion,  is  seldom  attacked.  In  certain  cases  it  may  affect  the 
entire  integument,  causing  general  exfoliative  dermatitis.  It  seldom 
influences  the  texture  of  the  skin,  so  that  pigmentation  and  cicatriza- 
tion do  not  occur. 

Etiology 

"We  know  but  little  about  the  nature  of  psoriasis;  attempts  to 
connect  it  with  causal  elements  produce  different  results  in  different 
countries.  There  is  no  doubt  that  the  disease  is  aggravated  by  what- 
ever influences  that  make  for  rheumatism  and  arthritism  so-called, 
such  as  cold  weather,  inactivity,  overeating,  etc.,  but  this  influence  can 
only  be  an  indirect  one.  Its  occurrence  in  members  of  the  same 
families  has  never  been  worked  out  satisfactorily.  We  do  not  know 
positively  that  the  disease  is  truly  a  familial  one,  for  it  is  possible 
that  it  is  mildly  contagious.  All  attempts  to  discover  and  isolate  a 
parasite  have  failed,  yet  the  course  of  the  lesions  sometimes  resemble 
strongly  that  of  known  parasitic  diseases. 

A  neuropathic  element,  often  markedly  in  evidence,  is  probably 
only  a  predisposing  factor.  As  already  stated,  the  affection  is  pri- 
marily one  of  the  epidermis — the  rete.  The  participation  of  the 
blood-vessels  and  the  papillary  layer  of  the  corium  appears  to  be 
secondary. 

Diagnosis 

The  initial  lesions,  already  described,  are  unmistakable;  and  a 
highly  developed  case,  with  its  universal  distribution  affecting  most 
markedly  the  extensor  surfaces  with  its  peculiar  scaliness  and  con- 
figuration, is  likewise  unmistakable.  Confusion  is  most  likely  to  occur 
in  isolated  patches,  say  those  on  the  scalp,  about  the  ears,  on  the 
elbows  and  knees,  etc.,  for  eczema  may  attack  the  same  localities  and 
present  much  the  same  appearance.  Exceptionally  localized  psoriasis 
has  been  seen  in  eczema  areas,  and  differentiation  is  so  difficult  that 
hybrid  types  are  spoken  of.  Whenever  scaly,  dry  eczema,  or  sebor- 
rhoic  dermatitis  appears  to  be  especially  resistant  to  treatment,  and 
to  return  promptly  and  without  manifest  cause,  it  is  well  to  study  the 

66 


case  closely  for  evidences  of  psoriasis.   In  these  cases  the  characteris- 
tic initial  lesions  may  be  detected. 

A  treated  psoriasis  is  often  impossible  of  recognition  at  first.  The 
previous  treatment  may  have  removed  the  scales,  so  that  we  see  only 
hyperemic  macules,  and  rings.  The  condition  may  be  readily  mis- 
taken for  a  papular  syphilide.  It  is  often  well  to  leave  such  cases 
without  local  treatment  for  a  few  days,  when  the  peculiar  crustlike 
scales  will  form.  In  some  cases,  however,  scaling  is  naturally  slight 
and  here,  of  course,  diagnosis  may  be  difficult.  Psoriasis  may  develop 
in  a  subject  with  syphilis.  Hence  the  Wassermann  reaction  may  be 
misleading. 

Prognosis 

Psoriasis  is  one  of  the  most  inveterate  of  all  affections,  but  it 
responds  to  treatment  to  a  notable  extent,  and  months,  often  years, 
may  elapse  between  outbreaks.  The  affection  is  not  progressive  with 
years,  and  leads  to  no  serious  consequences  of  any  sort.  Much  de- 
pends on  the  appearance  of  new  lesions,  for  in  some  subjects  these 
appear  almost  continually,  and  little  or  nothing  can  be  done  to  arrest 
them,  unless  the  process  is  relatively  slow  and  local,  when  if  put  on 
a  thorough  regimen  it  may  be  possible  to  check  the  outbreak.  Much 
also  depends  on  the  tendency  of  lesions  to  enlarge  and  form  patches 
of  size,  for  in  many  cases  the  spots  do  not  pass  beyond  the  guttate 
stage.  It  is  the  combination  of  these  two  factors  which  causes  the 
most  severe  cases.  The  more  vigorously  the  disease  is  combated 
the  better  should  be  the  prognosis;  but  there  are  exceptions,  for 
too  vigorous  treatment  sometimes  seems  to  inmiunize  the  skin  to 
the  favorable  action  of  the  remedies,  and  it  is  also  possible  for  a  case 
to  advance  steadily  despite  the  most  careful  treatment. 

Treatment 

On  a  carefully  selected  diet  and  regimen,  such  as  benefit  eczema 
and  acne,  psoriasis  also  improves.  Lesions  clear  up  when  training 
for  athletic  events  and  also  upon  low  plans  of  diet.  This  kind  of  man- 
agement naturally  renders  the  skin  a  more  unfavorable  culture  me- 
dium for  germs  of  all  kinds,  but  does  not  justify  the  claim  that 
psoriasis  is  due  to  a  germ.  No  matter  what  the  state  of  the  individual, 
attempts  should  be  made  to  render  all  his  functions  normal,  whether 
he  is  to  be  built  up  or  reduced.  Going  bare  in  the  outdoor  air  and 
sunlight  is  believed  by  Piffard  to  have  a  natural  curative  tendency. 

66 


K  any  well-marked  affection  is  present  it  should  be  treated  in  the 
hope  that  the  general  state  will  improve.  This  applies  especially  to 
anemia,  rheumatism  and  gout.  Arsenical  preparations,  including 
mineral  waters  which  contain  arsenic,  frequently  give  surprising  re- 
sults, but  it  is  often  best  to  save  this  resource  and  not  place  a  fresh 
case  upon  it,  for  the  patient  quickly  becomes  tolerant  to  it.  When 
there  is  urgent  need  that  a  patient  be  cleared  up  for  the  time  being, 
arsenic  pushed  to  the  limit,  combined  with  vigorous  local  treatment, 
may  effect  the  desired  result.  It  may  be  months  before  the  patient 
Avill  again  respond  to  arsenic.  Generally  speaking,  the  local  treat- 
ment of  chronic  eczema  may  always  be  essayed  in  psoriasis.  Many 
insist  that  alkalies  have  a  distinct  ability  to  control  the  disease ;  this 
might  be  true  of  paroxysms,  but  alkalies  are  not  suitable  remedies  to 
give  for  months.  The  benefit  ascribed  to  iodide  of  potassium  may  be 
due  to  the  alkali  and  not  the  iodine.  The  effect  of  alkalies  may  be 
secured  by  a  diet  made  up  largely  of  fruits  and  vegetables,  by  alkaline 
waters,  etc.  Alkalies  and  arsenic  given  simultaneously  may  prove 
more  efficacious  than  either  one  alone.  They  may  be  pushed  together 
or  alternately. 

Local  treatment  is  all-important  and  must  be  applied  with  refer- 
ence to  every  detail.  Some  of  the  agents  in  conunon  use  stain  the 
hair,  clothing  and  bedding.  It  is  not  well  to  use  the  best  ammunition 
in  incipient  or  mild  cases,  for  the  skin  soon  acquires  a  tolerance  to 
remedies.  As  a  rule,  scales  must  be  removed  in  connection  with  the 
treatment,  so  that  the  affected  epidermis  may  be  directly  acted  upon. 
To  insure  this  result,  bathing,  oils  and  salicylic  acid  ointment  cooper- 
ate. If  a  considerable  area  is  involved,  a  general  alkaline-starch  bath 
may  be  used.  Oil  inunctions  also  serve  to  loosen  the  scales.  The 
mere  removal  of  the  scales  sometimes  gives  the  impression  of  great 
benefit,  and  salicylic  acid  is  valuable  in  preventing  the  reappearance 
of  scales.  For  circumscribed  patches  on  the  knees  and  elbows,  an 
ointment  of  white  precipitate  may  be  sufficient  for  a  cure ;  and  it  is 
better  at  the  outset  to  use  minerals,  and  especially  tarry  preparations, 
saving  those  to  be  named  later  for  emergencies.  In  fact,  any  of  the 
remedies  found  useful  in  chronic  eczema  should  be  of  use  in  psoriasis, 
although  the  latter  will  prove  much  more  refractory. 

The  so-called  specifics,  chrysarobin  and  pjTogallol,  ■will  liave 
plenty  of  opportunity  for  full  testing.  Either  of  these  in  ointment 
form  will  cause  the  disappearance  of  psoriatic  patches,  but  must  not 
be  used  too  often,  lest  the  effect  be  lost.  Remedies  like  these  cannot 
b'e  used  in  rotation  very  long,  as  both  soon  lose  their  effect.    It  is 

67 


well,  as  soon  as  a  good  impression  is  made  with  these,  to  go  back 
to  tar  and  mercurials.  Betanaphthol  is  said  by  some  to  be  nearly  as 
good  as  the  two  remedies  mentioned. 


Fig.  54.     Model  in  Leaser's  Clinic  in  Berlin  (Kolbow). 

Fig.  55.     Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

Fig.  56.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

Fig.  57.     Model  in  Freiburg  Clinic  (Vogelbacher). 

Fig.  58.  Model  in  Neisser's  Clinic  in  Breslau  (Kroener).  A  man,  thirty- 
five  years  of  age,  who,  in  the  course  of  a  rather  extensive  eruption,  had 
manifestations  on  the  palms  and  soles. 

Figs.  59  and  60.     Models  in  Neisser's  Clinic  in  Breslau  {Kroener). 

Figs.  61  and  62.     Models  in  Neisser's  Clinic  in  Breslau  {Kroener).     , 

68 


Plate  39. 


E 

3 
o 

'3 

X3 


o 

J3 


E 

N 
O 

en 


Plate  40. 


E 

3 

'o 

J3 


o 


INl 

u 


in 


m 


Eczema  Seborrhoicum 

Synonyms:  Dermatitis  seborrhoica,  Seborrheic  eczema 
Plate  39,  Fig.  63;  Plate  40,  Figs.  64  and  65;  Plate  41,  Fig.  66 

This  affection  comprised  originally  no  more  than  the  so-called 
"inflamed  seborrhea" — salmon-colored  disklike  areas  covered  with 
a  greasy  scale  and  occurring  on  the  head  and  face,  sternal  and  intra- 
scapular  regions.  Exceptionally  this  eruption  had  a  general  distri- 
bution and  bore  a  more  or  less  striking  likeness  to  a  disseminated 
guttate  psoriasis.  Upon  this  substratum  Unna  proceeded  to  erect 
a  superstructure  of  disease  termed  by  him  seborrheic  eczema,  which 
could  be  so  stretched  as  to  include  a  great  deal  of  what  is  usually 
classed  as  ordinary  eczema.  Much  of  ordinary  dandruff  belongs 
here,  the  mere  production  of  the  fatty  scales  being  held  to  be  sufficient 
evidence  of  the  disease  even  in  the  absence  of  sensibly  inflamed 
scalp.  A  large  part  of  the  ordinary  eczema  of  the  scalp  is  also 
placed  here,  even  if  it  be  typical.  In  some  of  these  cases  the  presence 
of  ordinary  inflamed  seborrhea  of  older  authors  is  present  and  fre- 
quently extends  from  the  hairy  scalp  upon  the  smooth  skin  for  a 
short  distance.  The  middle  of  the  face — sides  of  the  nose  chiefly — 
is  a  common  site  of  inflamed  seborrhea,  the  skin  being  oily,  the 
sebaceous  glands  patulous  and  often  occluded  with  sebum,  \\dth 
maculopapular  lesions  of  pale  hue  and  surmounted  by  scales  or  fatty 
crusts.  These  lesions  have  affinities  with  acne  rosacea  and  lupus 
erythematosus,  and  in  fact  the  same  lesion  may  be  common  to  all  un- 
der certain  conditions.  The  obstinate  eczema  of  the  vermilion  border 
of  the  lip  is  also  claimed  as  seborrhoic,  when  it  is  associated  with 
seborrhea  of  the  scalp  or  nose. 

The  peculiar  lesions  over  the  sternum  and  between  the  scapulae 
have  usually  passed  for  eminently  characteristic  local  eruptions,  quite 
peculiar  to  the  localities  affected.  They  are  of  common  occurrence, 
and  when  we  see  them  we  may  usually  take  it  for  granted  that  the 
subject  has  dandruff  and  seborrhea  of  the  face. 

Patches  are  also  not  uncommon  in  the  armpits  and  genitocrural 


region.  While  in  some  cases  the  discrete,  pale-red  lesions  are  in  evi- 
dence, there  are  others  in  which  the  eruption  resembles  an  ordinary 
eczema  or  intertrigo.  A  diagnosis  can  only  be  made  through  col- 
lateral evidences  of  seborrheic  dermatitis  elsewhere. 

As  already  stated,  a  diffuse,  generalized  case,  where  guttate  le- 
sions are  found  over  the  limbs  as  well  as  the  trunk,  bears  a  striking 
resemblance  to  a  psoriasis,  which  is  either  less  scaly  than  common 
or  has  been  benefited  by  treatment.  In  some  of  these  cases,  however, 
diagnosis  is  easy,  for  there  are  principal  lesions  in  the  favorite 
localities  of  seborrhoic  dermatitis ;  the  lesions  have  a  peculiar  salmon 
color,  and  the  scales  are  greasy.  Eczema  seborrhoicum  of  the  scalp 
is  a  fertile  cause  of  premature  alopecia. 

Etiology 

It  was  long  held  that  in  ordinary  functional  seborrhea  the 
process  might  culminate  in  a  sort  of  adenitis  of  the  sebaceous  glands ; 
in  the  same  manner,  perhaps,  as  congestion  of  the  sweat-glands 
leads  to  prickly  heat.  This  view  was  succeeded  by  one  involving  in- 
fection of  the  glands  from  without,  and  resulting  dermatitis.  The 
suggestion  of  parasitism  is  much  stronger  here  than  in  ordinary 
eczema.  The  claim  has  been  advanced  that  the  sweat-glands  are  also 
involved.  Numerous  microorganisms  have  been  accused  of  causing 
this  affection.  No  progress  has  been  made  of  recent  years  in  our 
knowledge  of  the  latter,  which  for  the  present  is  very  defective. 

Diagnosis 

The  diagnostic  features  have  already  been  enumerated  in  part. 
The  disease,  wherever  else  present,  may  always  be  found  in  the 
scalp;  it  begins  there,  and  may  not  appear  elsewhere.  It  seems  to 
extend  downward,  for  its  next  most  conspicuous  place  is  the  face  and 
about  the  ears,  then  the  breast,  axillae  and  back,  and  so  on.  The  soil 
in  which  the  disease  develops  is  much  like  that  in  acne,  the  sebaceous 
glands  evidently  being  strongly  disposed  to  inflame.  The  inflamma- 
tion is  mild  in  degree,  focal,  and  produces  greasy  crusts.  Itching  is 
not  extreme,  and  scratch-marks  are  seldom  seen.  Wlien  it  does 
closely  simulate  ordinary  eczema,  the  locality  and  soil  may  be  suffi- 
cient to  exclude  the  latter. 

A  most  important  source  of  confusion  may  arise  in  the  case  of  an 
early  syphilide,  because  the  latter  produces  a  very  similar  appear- 
ance in  the  scalp.  A  generalized  case  may  also  resemble  a  syphilitic 
outbreak.    Syphilis,  psoriasis,  and  a  partially  cured  ringworm  may 

70 


all  simulate  seborrhea,  since  all  may  form  annular  lesions.  A  good 
diagnostic  resource  is  response  to  treatment,  which  should  be  much 
more  prompt  in  seborrhea. 

Prognosis 

A  tendencj'  to  recurrence  after  the  disappearance  of  the  lesions 
suggests  a  reinfection,  and  renders  the  course  uncertain  and  chronic. 

Treatment 

Sulphur  locally  is  regarded  as  a  specific,  although  not  much  used 
in  the  scalp.  The  principle  upon  which  sulphur  is  used  is  its  effi- 
cacy in  acne.  Other  valuable  remedies  are  salicylic  acid  and  resorcin. 
The  general  health  should  receive  attention.  Some  individuals  can- 
not use  alcoholics  without  greatly  aggravating  seborrhea  of  the  scalp. 
If  the  disease  proves  obstinate,  any  of  the  measures  used  in  obsti- 
nate cases  of  eczema  and  psoriasis  may  be  used,  and  the  same  is  true 
of  the  treatment  of  the  acnes,  which  may  also  be  employed  wdth  the 
idea  of  rendering  the  sebaceous  glands  less  disposed  to  inflame. 


Fig.  63.     Model  in  Freiburg  Clinic  (Johnsen). 

Figs.  64  and  65.     Models  in  Neisser's  Clinic  in  Brcslau  (Kroener). 

Fig.  66.     Half-ton^,  Dr.  Kingsbury,  New  York. 

71 


Pernio 

Synonyms:  Chilblains,  Erythema  pernio 
Plate  42,  Fig.  67 

Chilblains,  unless  severe,  do  not  claim  much  attention,  since  they 
are  an  almost  universal  consequence  of  the  seasons — the  beginning 
and  duration  of  the  cold  weather,  at  the  close  of  which  they  subside  of 
themselves.  But  conditions  strongly  suggestive  of  chilblains,  since 
they  involve  the  chilblain  area,  and  also  much  influenced  by  cold 
weather,  begin  like  ordinary  chilblains.  We  refer  here  to  Raynaud's 
disease  and  lupus  pernio.  The  chilblain  area  comprises  the  extremi- 
ties of  the  body — the  fingers,  toes,  heel,  nose  and  ears.  It  is  usually 
taken  for  granted  that  a  person  who  suffers  much  from  chilblains  has 
a  poor  circulation  and  is  anemic ;  and  doubtless  the  truth  of  this  claim 
might  be  readily  demonstrated.  As  a  matter  of  fact,  however,  one  of 
the  most  if  not  the  most  striking  factor  in  keeping  up  the  condition 
of  chilblains  is  the  sudden  warming  of  chilled  or  damp  feet  by  placing 
them  before  a  tire  or  standing  on  registers.  If  there  is  a  predisposi- 
tion, whether  due  to  defective  circulation  or  anemia,  a  slight  degree  of 
chilling  may  start  up  the  affection.  It  is  claimed  by  some  authorities 
that  chilblains  are  to  a  certain  extent  a  familial  affection. 

The  skin  in  the  chilblain  area  is  cold  to  the  touch,  red  or  livid  and 
edematous.  Itching  is  intense,  and  increased  by  warm  rooms,  contact 
with  bedding,  etc.  The  impaired  vitality  of  the  tissues  is  shown  by 
the  readiness  with  which  they  form  abrasions,  blisters  and  ulcers, 
which  heal  with  difficulty. 

Treatment 

Chilblains  may  be  prevented  by  treatment  instituted  before  the 
cold  weather  begins.  Tonics  should  be  given,  and  an  attempt  made  to 
harden  the  tissues  with  cold  bathing.  Itching  should  be  controlled  by 
ordinary  antipruritics.  Anything  which  antagonizes  the  condition  of 
stasis  should  be  of  value. 

Fig.  67.    Model  in  Neisser's  Clinic  in  Breslau  (Kroener). 

72 


Plate  42. 


CI 


•a 

Ci 


CO 


bp 


t— • 
o 


Oh 

o 


Raynaud's  Disease 

Plate  42,  Fig.  68 

This  affection  is  a  vasomotor  neurosis  which  is  described  at  great 
length  in  works  on  neurology  and  in  special  monographs.  It  belongs 
to  the  so-called  acroneuroses  and  is  therefore  limited  to  the  extremi- 
ties— fingers,  toes,  ears,  and  exceptionally  the  tip  of  the  nose.  It  is 
believed  to  result  from  a  persistent  angiospasm  of  the  terminal  arter- 
ies and  veins,  although  the  same  condition  may  be  produced  by  an 
actual  arteritis.  It  stands  in  a  certain  definite  relationship  to  the  so- 
called  chilblain  area,  and  appears  to  attack  individuals  with  a  sluggish 
terminal  circulation  who  are  predisposed  to  cold  extremities  and  chil- 
blains. The  persistent  vascular  disturbances  tend  to  terminate  in 
extensive  trophic  alterations,  the  most  significant  of  which  is  dry  gan- 
grene, Avhence  the  sjaionym  "symmetrical  gangrene."  One  or  more 
digits  may  be  involved  on  each  hand  or  foot. 

The  early  sjonptoms  vary  considerably,  due  no  doubt  to  the  rela- 
tive part  played  by  the  arterioles  and  venules,  and  also  to  the  fact  that 
the  initial  spasm  of  the  vessels  may  be  followed  by  paresis.  Further, 
the  affection  develops  in  a  series  of  exacerbations  with  quiescent  in- 
tervals between.  The  fingers  are  often  seen  to  be  white  and  cold,  this 
phase  of  the  process  indicating  intense  local  anemia  from  angiospasm 
of  the  arterioles.  This  stage  is  by  no  means  necessarily  present,  and 
the  malady  may  begin  witli  what  is  termed  the  second  stage.  It  is 
impossible  to  state  to  what  extent  this  is  due  to  venous  angiospasm. 
The  fingers  become  red  and  congested,  as  if  from  the  cold,  the  color 
usually  deepening  as  the  disease  advances.  Even  in  the  early  period 
the  extremities  may  have  an  intense  cyanotic  hue.  The  statement 
that  angiospasm  is  necessarily  followed  by  a  condition  of  vascular 
relaxation  does  not  seem  reasonable,  for  the  vascular  changes  must 
be  essentially  obstructive  in  order  to  cause  gangrene.  The  latter  is 
not  a  necessary  development,  for  the  condition  may  never  progress 
thus  far.  The  gangrene  may  also  be  very  sliglit  and  superficial  or,  in- 
stead of  necrosis,  trophic  ulcers  or  atrophy  may  develop.    It  must 


never  be  forgotten  that  Raynaud's  disease  is  not  infrequently  com- 
bined with  one  of  the  other  acroneuroses,  notably  scleroderma,  ery- 
thromelalgia,  and  perhaps  acroparesthesia.  These  complications 
naturally  give  rise  to  atypical  cases.  The  uncomplicated  disease  is 
not  characterized  by  much  subjective  disturbance. 

Diagnosis 

It  is  often  difficult  to  distinguish  Raynaud's  disease  at  its  outset 
from  the  other  acroneuroses.  As  already  stated,  transition  forms 
occur,  and  the  different  affections  really  form  a  group  disease.  There 
is  considerable  resemblance  at  times  to  the  lesions  of  syringomyelia. 
It  has  been  said  that  Raynaud's  disease  cannot  possibly  be  distin- 
guished from  s>i5hilitic  arteritis,  the  crippling  of  the  peripheral  cir- 
culation being  practically  the  same.  Arteritis  of  some  sort  is  no  doubt 
responsible  for  a  certain  per  cent,  of  cases.  A  Wassermann  test 
should  be  made  as  a  matter  of  routine. 

Prognosis 

This  is  good  for  life,  but  rather  poor  for  recovery.  The  gangre- 
nous tissues  separate  in  time,  and  the  exposed  surfaces  heal  slowly. 
Amputation  is  seldom  required.  The  disease  may  reappear  in  other 
fingers,  so  that  we  may  see  the  different  aspects  side  by  side. 

Treatment 

This  includes  all  measures  which  may  favorably  modify  the  cir- 
culation, including  general  regimen.  Hydrotherapy,  massage,  galvan- 
ism and  faradism  have  all  been  used  extensively.  In  the  later  stages 
strict  asepsis  is  required,  as  infection  from  without  readily  occurs  and 
fatal  sepsis  has  been  known  to  result. 


Fig.  68.     Model  in  Neisser's  Clinic  in  Breslau   (Kroener).     See  Transac- 
tions of  Demiatol.     Congress  in  Breslau,  1901. 

74 


Plate  43. 


Fig.  69.  Gangrena  diabetica. 


Diabetic  Gangrene 

Plate  43,  Fig.  69 

Localized  cutaneous  gangrene  frequently  occurs  in  cases  of  ad- 
vanced diabetes  mellitus.  The  extremities  are  generally  affected,  par- 
ticularly the  toes  and  fingers.  Occasionally  the  penis  is  involved. 
Although  the  gangrene  may  be  of  any  familiar  type,  Kaposi  has 
described  a  form  believed  to  be  peculiar  to  this  affection.  It  is  seen 
only  in  advanced  cases,  and  consists  of  a  serpiginous  grouping  of  bul- 
lae occurring  on  the  limbs  in  successive  crops.  A  black  scab  then 
forms,  which  is  surrounded  by  a  ring  of  new  bullae.  The  corium  is 
involved,  and  after  all  scabs  have  come  away,  a  portion  of  it  sloughs. 
This,  in  turn,  being  thrown  off,  leaves  a  granulating  surface. 

Prognosis 

This  should  always  be  guarded,  as  the  gangrene  occurs  only  in 
individuals  suffering  from  advanced  diabetes. 

Treatment 

This  has  never  been  very  satisfactory.  For  the  underlying  condi- 
tion, general  medical  and  dietetic  measures  are  of  course  indicated. 
When  gangrene  is  established  its  advance  is  often  controlled  by  the 
frequent  application  of  warm  antiseptic  dressings.  In  beginning  dia- 
betic gangrene  of  the  fingers  good  results  have  recently  been  reported 
following  the  employment  of  Schaeffer's  hot  air  method  of  treatment. 
The  intense  heat  is  said  to  force  new  blood  into  the  stagnating  blood- 
vessels and  by  re-establishing  the  circulation  aborts  the  process. 


Fig.  69.    Model  in  Neisser's  Clinic  in  Breslau  (Kroener)- 

75 


Ecthyma  Gangrenosum 

Synonym:    Dermatitis  gangrenosa  infantum 
Plate  44,  Fig.  70 

This  affection,  while  peculiar  to  young  children,  corresponds  to 
multiple  spontaneous  gangrene  in  adults.  A  study  of  the  literature 
conveys  a  strong  impression  that  a  distinct  disease  as  described  by 
some  authors  does  not  really  exist.  If  we  state  that  in  certain  cachec- 
tic infants  nearly  any  eruption  may  become  gangrenous  under  certain 
unknown  conditions,  there  is  not  much  to  add. 

Hutchinson  first  described  the  condition  as  a  sequel  of  varicella, 
under  the  name  varicella  gangrenosa.  A  similar  termination  was 
noted  in  vaccinia.  Other  cases  were  described  as  pemphigus  gan- 
grenosus.  French  authors  regard  it  simply  as  ecthyma  with  a  ne- 
crotic tendency,  and  term  it  terebrant  or  boring  ecthyma,  rather  than 
gangrenous ;  for  in  gangrene  we  naturally  expect  to  see  more  lateral 
extension.  The  term  rupia  escharotica  conveys  the  impression  of 
firmly  adherent  crusts,  beneath  which  necrosis  occurs,  either  from 
pressure  or  through  the  action  of  anerobic  bacteria. 

The  chief  interest  lies  in  the  purely  spontaneous  cases,  which  are 
said  to  begin  as  small  papulopustules  or  vesicles  about  the  buttocks. 
In  a  case  described  a  few  years  ago  by  Welander,  in  a  young  infant, 
the  head  was  the  seat  of  the  lesions,  although  the  statement  has  been 
made  that  the  head  is  never  attacked.  The  disease  may  run  a  rela- 
tively mild  or  a  severe  and  fatal  course,  and  there  may  be  only  a  few 
lesions  or  many.  It  has  been  shown  to  be  independent  of  tuberculosis 
and  also  of  syphilis.  No  evidence  of  pathogenic  germs  constantly 
present  has  been  adduced,  nor  is  it  even  known  whether  such  germs 
are  inoculated  from  without  or  gain  the  surface  from  within.  In  fatal 
sepsis  a  few  small  necrotic  pustules  have  been  seen  in  the  skin  as  if 
produced  by  emboli  of  germs,  but  they  bear  no  clinical  relation  to 
this  affection. 

From  the  fact  that  the  lesions  are  usually  seen  about  the  region  of 

70 


Plate  44. 


Fig.  70.  Ecthyma  gangrenosum. 


the  buttocks,  it  has  beon  thought  that  they  have  resulted  from  inocula- 
tion from  feces  or  other  outward  source.  They  have,  however,  been 
seen  to  cover  the  abdomen  and  limbs,  also,  as  above  stated,  the  head. 
To  sum  up,  when  the  affection  is  not  secondary  to  some  well- 
knowTi  eruption,  like  varicella,  it  appears  to  begin  as  papulopustules 
or  vesicopustules,  which  lead  to  crust-formation.  Destruction  of  tis- 
sue takes  place  beneath  and  around  the  crusts  and  an  ecthymatous 
lesion  is  produced,  i.e.,  a  large  pustule  with  a  hard,  inflamed  base. 
The  crusts  come  away,  leaving  ulcers,  which,  if  the  lesions  are  close 
enough  together,  may  become  confluent,  but  no  diffuse  gangrene 
results.    Permanent  scars  naturally  result. 

Treatment 

This  is  carried  out  by  ordinary  antiseptic  dressings,  with  tonics 
and  good  nursing. 


Fig.  70.     Model  in  Kaposi's  Clinic  in  Vienna  (Hennmg). 

77 


Ulcer  from  Roentgen  Rays 

Plate  45,  Fig.  71 

The  Roentgen  rays  cause  various  degrees  of  injury  to  the  skin 
and  subjacent  tissues,  as  a  result  either  of  oversensitiveness  or  ex- 
cessive dosage,  the  latter  being  largely  preventable,  as  should  also  be 
the  results  of  accidental  exposure.  The  changes  caused  somewhat 
resemble  the  different  degrees  of  sunburn,  and  there  are  also  trophic 
alterations,  such  as  shedding  of  the  hair.  After  a  period  of  latency, 
occupying  in  some  cases  several  days,  the  characteristic  erythema  or 
dermatitis  supervenes.  The  mildest  degree  is  much  like  the  erythema 
due  to  the  solar  rays  and  likewise  tends  to  leave  pigmentation.  With 
repeated  or  severe  exposures  or  undue  sensitiveness  a  vesicular  der- 
matitis results.  Unlike  sunburn,  a  deeper  degree  of  injury  sometimes 
occurs  in  which  superficial  necrosis  develops,  leaving  a  large  raw  sur- 
face covered  perhaps  with  an  adherent  false  membrane.  These  are 
not  only  extremely  painful  but  show  little  or  no  tendency  to  cicatrize. 
There  is  also,  so  to  speak,  a  fourth  degree  of  injury,  in  which  the 
subcutaneous  tissues — muscles,  bone,  etc. — may  also  slough,  leaving 
deep  losses  of  substance.  Hence  the  two  severe  degrees  of  X-ray 
injury  are  not  unlike  burns  of  the  third  and  fourth  degrees.  They 
appear  to  be  due  primarily  to  injury  to  the  blood-vessels.  Those  who 
work  continually  ■\\ath  the  rays  also  suffer  from  atrophy  of  the  skin 
of  the  hands  and  forearms,  and  the  development  of  epithelioma  is  not 
infrequent. 

Treaimeni 

The  milder  degrees  of  injury  are  managed  like  dermatitis  and 
acute  eczema.  The  ulcers  are  often  very  painful  and  anodjmes  are 
frequently  indicated,  orthof orm  being  the  most  useful.  In  deep  ulcers 
excision  followed  by  skin  grafting  may  be  practiced  but  owing  to  the 
peculiar  pathological  change  that  has  taken  place  in  the  tissue  sur- 
rounding the  ulcer  the  surgical  results  are  often  disappoiiating. 

Fig.  71.     Model  in  Freiburg  Clinic  {Vogelbacher). 

78 


Plate  45. 


Tig.  71.  Ulcer  from  Roentgen  Rays. 


Plate  46. 


Fig.  72.  Pellagra. 


Plate  47. 


Fig.  73.  Pellagra. 


Pellagra 

Plates  46  and  47,  Figs.  72  and  73 

Pellagra  is  a  general  disease  with  important  and  characteristic 
cutaneous  manifestations  which  serve  for  its  recognition.  It  was  at 
first  thought  to  be  peculiar  to  certain  countries  in  southern  Europe,  in 
which  it  is  endemic,  notably  parts  of  Spain  and  Italy.  In  compara- 
tively recent  times  it  has  been  seen  both  sporadically  and  epidemically 
in  various  localities  in  both  hemispheres.  It  is  clearly  not  peculiar  to 
warm  climates,  although  practically  confined  to  them.  The  earliest 
cases  seen  in  the  United  States  were  in  native  subjects,  and  confined 
to  the  insane.  They  are  known  as,  or  presumed  to  have  been,  pellagra 
from  the  records  of  institutions,  although  not  recognized  at  the  time. 
In  quite  recent  years  a  few  imported  cases  have  been  noted  in  the 
United  States.  The  great  bulk  of  American  cases,  however,  have 
appeared  within  the  last  decade,  and  in  the  Southern  States,  where 
pellagra  now  prevails  to  an  alarming  extent.  It  has  recently  been 
asserted  that  the  disease  may  be  found  described  in  the  annals  of 
Spanish  America  at  a  date  much  earlier  than  the  oldest  European 
records. 

Owing  to  its  severe  constitutional  symptoms,  chiefly  manifested  in 
the  nervous  system  and  gastro-enteric  tract,  pellagra  is  relatively  un- 
important as  a  dermatosis.  A  large  proportion  of  cases  find  their 
way  to  insane  asylums.  The  eruption  of  pellagrins  is  confined  to  a 
desquamating  erythema  of  the  face  and  backs  of  the  hands  and 
wrists,  which  extends  for  a  variable  distance  up  the  forearms;  this 
is  a  chronic  condition  which  in  time  shows  a  slight  degree  of  thicken- 
ing and  deposition  of  pigment.  A  certain  amount  of  atrophy  may 
remain. 

The  patient  seems  at  first  to  suffer  from  spring  lassitude  along 
with  disordered  digestion.  The  latter  may  involve  almost  the  entire 
digestive  tract — stomatitis,  epigastric  pain,  anorexia,  and  diarrhea. 
The  patient  becomes  weak  and  easily  fatigued.  After  several  weeks 
of  these  prodromes,  the  parts  exposed  to  the  weather — face,  portions 
of  the  upper  extremity  already  mentioned,  and  the  tops  of  the  feet 
and  ankles,  in  those  exposed,  assimie  a  deep  red  hue  with  a  tendency 
to  become  brown.     That  the  sun  and  wind  are  only  predisposing 

79 


causes,  as  in  the  case  of  freckles,  is  apparent  from  the  fact  that  in 
rare  instances  the  erythema  has  been  seen  on  non-exposed  regions. 
The  process  may  be  very  superficial  or  deeper,  and  in  the  latter  case 
results  in  more  or  less  thickening.  Peeling,  pigmentation  and  atro- 
phy, these  sequelae  of  the  inflammatory  process,  are  often  seen  side 
by  side,  forming  a  picture  which  could  not  be  mistaken  for  any  other 
affection.  The  skin,  thinned  and  wrinkled,  and  deeply  pigmented, 
sometimes  shows  diminished  sensibility.  The  amount  of  cutaneous 
participation  is  no  index  of  the  general  severity  of  the  disease.  In 
the  more  acute  forms  the  patient  may  die  before  erythema  develops. 
The  course  of  the  skin  lesions  follows  the  seasons,  improving  or  dis- 
appearing in  the  fall,  probably  to  reappear  in  the  spring.  The  peeling 
is  an  integral  part  of  the  disease  and  not  a  mere  sequel  of  the 
erythema.  Even  when  the  skin  has  become  atrophic  the  epidermis 
comes  away  in  large  flakes.  Several  years  are  required  for  the  com- 
bined cycle  of  changes  in  the  skin.  The  patients  are  doomed  to 
disability  and  very  often  to  early  death.  There  are,  however,  degrees 
of  severity  and  in  the  mildest  the  patient  may  live  for  many  years 
and  sometimes  recover.  In  a  virgin  community  the  disease  is  more 
severe  and  few  survive. 

Etiology 

Of  this  absolutely  nothing  is  known.  It  is  probable  that  two  fac- 
tors act  in  association.  One  is  a  living  cause,  and  the  other  a  vehicle 
which  is  probably  articles  of  diet.  The  spoiled  Indian  meal  so  often 
accused  cannot  cause  all  the  cases.  We  know  now  tliat  the  prosperous 
and  well-fed  may  become  affected.  It  is  believed  that  solar  rays  are 
somehow  responsible,  in  that  they  may  liberate  a  poisonous  principle 
in  the  tissues.  As  a  pseudo-pellagra  has  been  caused  by  various 
agencies — alcoholism,  and  perhaps  ergotism — it  has  been  held  that 
pellagra  is  a  mere  syndrome.  The  actual  lesions  which  cause  death 
seem  to  be  intracranial — pachymeningitis  and  cerebral  sclerosis. 

Diagnosis 

Only  in  the  early  stage  could  any  confusion  arise.  The  disease 
while  it  may  attack  all  ages  is  not  a  child's  malady,  but  inclines  to 
affect  matured  people  exposed  to  the  weather.  No  one  should  con- 
fuse pellagra  with  sunburn,  for  it  appears  in  the  spring  and  not  at  the 
beginning  of  summer.  We  sometimes  find  a  crude  simulation  of 
pellagra  in  wretched  cachectic  and  alcoholic  subjects. 

Treatment 

On  the  first  appearance  of  the  disease  when  the  type  is  mild,  vigor- 
ous constitutional  treatment  with  change  of  diet  and  surroundings 

80 


ought  to  benefit  the  patient.  Arsenic  and  thyroid  substance  are  two 
remedies  which  are  believed  to  have  some  specific  virtues.  That  a 
severe  blood  dyscrasia  is  present  seems  to  follow  from  the  favorable 
results  of  transfusion  in  severe  cases.  Local  treatment  is  hardly 
mentioned  by  authors;  but  as  considerable  itching  is  present  the 
management  of  acute  eczema  ought  to  be  transferable  to  pellagra. 


Figs.  72  and  73.  Model  in  the  Dcrmatological  Clinic  of  the  University  in 
Innsbruck  (Henning).  The  reproduction  of  tiiis  model,  wiiich  was 
first  published  in  a  Monograph  by  Prof.  Merck,  "Skin  Manifestations 
m  Pellagra,"  was  kindly  permitted  by  the  author. 


81 


Variola 

Synonym:  Smallpox 
Plate  48,  Fig.  75 ;  Plate  49,  Fig.  76 

Variola  is  an  acute  infectious  disease  of  unknown  causation:  a 
protozoon  has  been  described  but  has  not  been  definitely  proven  to  be 
the  causative  agent. 

Among  those  unprotected  by  vaccination,  variola  is  the  most  viru- 
lent of  all  contagious  diseases. 

The  period  of  incubation,  when  the  disease  is  inoculated,  is  eight 
to  nine  days ;  when  it  is  transmitted  by  contagion,  it  is  ten  to  fourteen 
days,  and  occasionally  longer.  All  persons  exposed  should  be  kept 
under  observation  for  at  least  three  weeks. 

Onset  is  sudden  with  severe  chills,  high  fever,  temperature  103° 
to  105°  F.,  intense  backache  and  pains  in  the  legs,  vomiting,  frequently 
delirium  and  in  children  convulsions. 

Prodromal  eruptions,  when  they  occur,  appear  usually  on  the  sec- 
ond day.  They  may  be  morbilliform  or  erythematous  in  character 
and  may  be  hemorrhagic,  and  are  most  marked  on  the  lower  part  of 
the  abdomen,  inner  surface  of  the  thighs,  the  axillae  or  lateral  thoracic 
region;  occasionally  they  occur  on  the  extensor  surfaces,  especially 
of  the  knees  and  elbows.  The  erythematous  type  limited  to  the  lower 
part  of  the  abdomen  and  inner  surface  of  the  thighs  is  seen  especially 
in  pregnant  women. 

The  characteristic  eruption  appears  on  the  fourth  day,  first  on 
the  forehead  and  face,  and  spreads  rapidly  over  the  whole  body,  in- 
volving the  mucous  membranes  of  the  eyes,  mouth,  and  throat;  but 
it  is  always  most  marked  on  the  face  and  hands.  The  eruption  con- 
sists at  first  of  hard,  small,  shotlike  papules  which  rapidly  increase 
in  size  and  gradually,  usually  by  the  end  of  the  second  or  third  day, 
become  vesicular.  These  vesicles  are  always  umbilicated,  and  after 
another  two  or  three  days  their  contents  become  purulent.  As  the 
pustules  develop,  the  temperature,  which  had  gone  dowoi  with  the 

82 


Plate  48. 


_o 
> 

c 


> 

bJO 


development  of  the  papules,  rises  again.  The  pustules  begin  to  dry 
up  and  crust  in  about  ton  days. 

At  this  time  the  temperature  falls  and  there  is  a  general  improve- 
ment of  all  sjTiiptoms.  The  crusts  usually  come  off  and  leave  com- 
pletely healed  lesions  by  the  twenty-first  day. 

In  addition  to  the  above  or  regular  tj^De  we  have  hemorrhagic 
smallpox,  which  occurs  in  two  forms:  first — purpura  variolosa:  in 
this  form  at  the  end  of  the  second  or  on  the  third  day  an  ervthematous 
rash  appears,  especially  in  the  groins,  with  small  punctiform  hemor- 
rhages; the  rash  extends,  rapidly  becoming  more  and  more  hemor- 
rhagic, ecchymoses  appearing  in  the  conjunctiva — and  hemorrhages 
from  mucous  membranes.  This  tj-pe  is  rapidly  fatal — death  occur- 
ring on  the  third  to  fifth  day.  Second  form  or  variola  hemorrhagica 
pustulosa:  in  this  form  hemorrhages  occur  when  the  rash  reaches 
the  vesicular  or  pustular  stage.  Bleeding  from  mucous  membranes 
is  common  and  the  mortality  is  high — death  occurring  on  the  seventh 
to  ninth  day.  Occasionally  cases  are  seen  where  bleeding  takes  place 
into  the  lesions  in  the  vesicular  stage,  followed  by  rapid  abortion  of 
the  rash  and  speedy  recovery. 

Varioloid,  modified  smallpox,  seen  in  persons  who  have  been  suc- 
cessfully vaccinated,  sets  in  abruptly  like  the  regular  type,  but  the 
sjTnptoms  are  usually  milder,  the  number  of  the  lesions  are  very 
much  less  and  may  be  limited  entirely  to  the  face  and  hands;  the 
temperature  drops  rapidly,  the  lesions  soon  dry  up  and  there  is  no 
secondary  fever. 

Diagnosis 

The  prodromal  rashes  are  to  be  differentiated,  first,  from  measles 
by  the  severity  of  the  constitutional  sjTnptoms,  the  absence  of 
Koplik's  spots,  the  absence  of  lacrjination  and  coryza,  and  by  the 
early  appearance  of  the  rash  on  the  trunk  instead  of  on  the  face  and 
neck  as  in  measles.  Secondly,  from  scarlatina  by  the  initial  symptoms 
and  the  absence  of  the  angina  and  scarlet  tongue. 

The  regular  rash  must  be  differentiated  chiefiy  from  varicella. 
This  is  done  by  the  severity  of  the  onset,  the  duration  of  the  prodro- 
mal SjTnptoms,  the  site  where  the  rash  first  appears — in  varicella  the 
rash  first  appears  on  the  trunk — and  the  indi\'idual  characteristics  of 
the  lesions.  The  papules  in  variola  are  always  hard  and  shotty  and 
last  about  two  days ;  in  varicella  the  papules  are  not  indurated  and  be- 
come vesicular  in  a  few  hours.  The  vesicles  of  variola  are  always 
umbilicated  and  do  not  collapse  when  ruptured ;  in  varicella  they  may 

83 


be  umbilicated,  but  they  are  superficial  and  do  collapse  when  rup- 
tured. The  most  characteristic  and  important  point,  however,  is  that 
the  lesions  in  variola  are  all  in  the  same  stage  on  the  same  site,  while 
in  varicella  the  lesions  come  out  in  crops,  and  we  find  papules,  ves- 
icles, pustules  and  crusts  intermingled  in  the  same  region.  The 
lesions  in  variola  are  comparatively  most  numerous  on  the  face  and 
hands — in  varicella  they  are  comparatively  most  numerous  on  the 
back. 

From  pustular  syphilis  it  is  diagnosed  by  the  history  of  the  onset, 
the  history  of  the  development  of  the  rash — the  absence  of  mucous 
patches  and  condylomata.  A  negative  Wassennann  would  also  be  of 
great  aid  in  the  diagnosis. 

Prognosis 

In  the  hemorrhagic  types  it  is  very  bad.  In  the  regular  type  it 
varies  directly  with  the  severity  of  the  disease,  from  bad  in  the  con- 
fluent form  to  favorable  in  the  discrete  form.  In  varioloid  it  is  very 
good. 

Prophylaxis 

Everyone  should  be  vaccinated  regularly  every  three  or  four 
years,  and  if  exposed  to  the  disease  revaccination  is  imperative. 

To  prevent  the  spread  of  the  disease,  all  cases  occurring  in  cities 
or  thickly  settled  communities  should  be  isolated  in  suitable  hospitals. 
All  persons  exposed  should  be  inspected  daily  for  at  least  twenty- 
one  days. 

All  bedding  and  clothing  that  has  come  in  contact  with  the  patient 
should  be  thoroughly  disinfected  either  by  boiling  or  steam  steriliza- 
tion. If  this  cannot  be  done,  it  should  be  burned.  The  premises  from 
which  a  case  has  been  removed  should  be  fumigated  with  either  sul- 
phur or  formaldehyde,  using  four  pounds  of  sulphur  for  every  1,000 
cu.  ft.  of  air  space  and  eight  hours'  exposure  or  six  ounces  of  formalin 
per  1,000  cu.  ft.  of  air  space  and  five  hours'  exposure.  After  fumiga- 
tion the  premises  should  be  washed  with  a  1  to  1000  solution  of 
bichloride  of  mercury.  All  excreta  should  be  sterilized  with  a  5% 
solution  of  phenol  or  a  1  to  1000  solution  of  bichloride  of  mercury. 

In  case  of  death  the  body  should  be  wrapped  in  a  sheet  saturated 
■with  a  1  to  1000  bichloride  solution  and  interred  in  a  metal  lined  coffin. 

Treatment 

Absolute  rest  in  bed  from  the  beginning  until  the  secondary  fever 
lias  subsided.    The  diet  during  this  period  should  be  liquid. 

84 


For  the  intense  headache  and  backache  morphia  by  hypodermic 
injection  gives  the  best  result  and  should  be  given  early.  Dover's 
powder  is  occasionally  satisfactory  in  relieving  the  insonmia.  The 
temperature  can  be  best  controlled  by  hydrotherapy. 

The  eyes  must  be  kept  scrupulously  clean  by  repeated  Avashings 
with  boric  acid  solution.  For  the  nose  and  throat  a  dilute  Dohell's 
solution  or  a  2%  boric  acid  solution  is  useful. 

Scrupulous  cleanliness  is  absolutely  necessary  during  the  whole 
course  of  the  disease  and  the  patient  should  receive  daily  baths,  tak- 
ing care  not  to  rupture  the  vesicles  or  pustules  on  the  face. 

The  red  light  treatment  has  received  considerable  attention  re- 
cently; to  be  of  any  value  it  must  be  carried  out  absolutely,  making 
it  necessary  to  have  only  red  glass  in  all  -windows  and  lighting  fix- 
tures, and  a  vestibule  with  double  doors  so  that  not  a  single  ray  of 
white  light  can  enter  the  room  or  ward.  The  red  light  is  very 
trying  on  the  eyes  of  both  patients  and  attendants,  and  the  results 
hardly  justify  the  inconvenience  it  causes. 

The  prevention  of  scarring  is  practically  impossible,  but  carbol- 
ized  ointments  or  lotions  should  be  applied  to  the  face  to  relieve  the 
intense  pruritus. 

During  the  stage  of  pustulation,  stimulants  are  almost  always 
necessary:  the  best  are  whiskey  and  strychnine;  to  an  adult  half  an 
ounce  of  whiskey  and  strj'chnia  sulphate  gr.  Ho  can  be  given  every 
four  hours. 

The  delirium  is  best  treated  by  bromides  and  morphia. 

The  crusts,  which  are  usually  ready  to  come  off  in  twenty-one 
days,  should  be  completely  removed  before  the  patient  is  discharged ; 
but  care  must  be  taken  to  see  that  no  moist  or  raw  spots  exist  and 
that  all  crusts  have  been  removed  from  the  palms  and  soles  and  from 
under  the  edges  of  toe  and  finger  nails. 

Complications 

Purulent  conjunctivitis  is  frequent  and  is  to  be  avoided  by  fre- 
quent and  careful  cleansing  of  the  eyes.  "WTien  it  develops  it  is  to  be 
treated  the  same  as  conjunctivitis  from  any  other  cause — cold  com- 
presses— ^boric  acid  washings  sufficiently  frequent  to  keep  the  eyes 
clean.  Solution  of  argyrol  (20%)  every  four  hours  or  a  1%  to 
2%  solution  of  silver  nitrate  painted  over  the  conjunctiva  once  or 
twice  a  day.  If  a  keratitis  sliould  develop  the  cold  compresses  should 
be  changed  to  hot  ones — the  pupils  must  be  kept  dilated  with  a  1% 
solution  of  atropine  sulphate.    The  cleansing  with  the  boric  acid  solu- 

85 


tion  is  to  be  continued,  and  if  corneal  ulcers  develop  it  may  be  neces- 
sary to  cauterize  them  with  tincture  of  iodine  or  the  galvano  cautery. 

Laryngitis  is  frequent  and  may  cause  necrosis  of  the  cartilages 
and  be  followed  by  broncho-pneumonia,  or  may  cause  edema  of  the 
glottis,  necessitating  tracheotomy;  intubation  is  not  satisfactory  in 
these  cases.  The  throat  complications  are  best  avoided  and  treated  by 
spraying  or  gargling  with  aUcaline  solutions  or  with  a  hot  normal  salt 
solution.  In  beginning  edema  of  the  glottis  an  ice  collar  is  frequently 
of  service,  at  other  times  hot  poultices  seem  to  give  better  results. 

Otitis  media  sometimes  occurs.  As  soon  as  the  drum  membrane 
is  red  and  bulging  it  should  be  incised  and  the  ear  irrigated  with  hot 
boric  acid  solution  sufficiently  often  to  keep  it  clean.  If  tenderness 
develops  over  the  mastoid  it  should  be  opened  at  once,  the  mastoid 
cells  completely  removed  and  the  antrum  drained. 

Albuminuria  is  frequent,  but  a  true  nephritis  is  rare ;  if  it  occurs, 
however,  the  patient  should  be  given  plenty  of  pure  water  and  placed 
on  a  milk  diet;  diuretics  are  seldom  necessary.  If  suppression  of 
urine  develops,  hot  packs  and  high  saline  irrigations  are  indicated. 
In  robust  patients  bleeding  is  often  of  considerable  benefit. 

Multiple  abscesses  are  frequently  seen  and  are  at  times  extremely 
troublesome.  They  should  be  opened  as  soon  as  fluctuation  is  de- 
tected, drained,  and  packed. 

The  characteristic  pitting  that  is  often  such  a  disfiguring  sequelae 
to  the  disease,  is  always  permanent.  Treatment  is  most  unsatisfac- 
tory. Fibrolysin  and  thiosinanim  are  useless  and  massage  and 
electrical  applications  of  but  little,  if  any,  benefit. 


Fig.  75.     Model  by  Kolbow,  of  Berlin. 
Fig.  76.     Model  by  M.  Trammond,  Paris  {Jumelin). 

86 


Plate  49. 


Fig.  76.  Variola. 


Fig.  77.  Varicella  in  adult. 


Plate  50. 


Fig.  78.  Varicella. 


Varicella 

Synonym :  Chicken-pox 

Plate  48,  Fig.  74;  Plate  49,  Fig.  77;  Plate  50,  Fig.  78 

This  is  an  acute  contagious  disease  of  unknown  causation,  having 
a  period  of  incubation  from  ten  to  fifteen  days.  Although  generally 
regarded  as  an  affection  of  childhood,  its  occurrence  in  adults  is  not 
as  rare  as  is  commonly  supposed. 

The  prodromal  symptoms  are  of  short  duration,  lasting  as  a  rule 
but  a  few  hours.  They  consist  of  slight  fever,  chilliness,  nausea,  with 
occasional  vomiting,  pain  in  the  back  and  legs,  and  very  rarely 
convulsions. 

The  eruption  generally  appears  first  on  the  back  or  chest,  although 
frequently  first  seen  upon  the  face.  It  consists  of  small  superficial 
papules  which  rapidly  become  vesicles,  and  at  the  end  of  about  thirty- 
six  hours  after  the  first  appearance  of  the  rash  the  contents  of  these 
vesicles  have  become  purulent.  The  vesicles  are  often  ovoid  in  shape, 
very  superficial,  and  the  skin  around  them  is  neither  infiltrated  nor 
hyperemic.  Occasionally  some  of  the  vesicles  are  found  to  be  um- 
bilicated.  During  the  third  and  fourth  day  the  lesions  dry  up  and  are 
covered  wdth  a  browmish  crust  which  soon  falls  off,  and  as  a  rule 
leaves  no  scar.  Fresh  crops  of  papules  continue  to  develop  during 
the  first  three  days,  giving  the  characteristic  picture  of  intermingled 
papules,  vesicles,  pustules  and  crusts. 

The  lesions  are  most  numerous  on  the  trunk,  but  the  extremities, 
face,  and  scalp  are  also  affected.  They  are  seldom  seen  on  the  palms 
and  soles,  although  they  occur  here  in  severe  cases.  The  lips  and 
mucous  membranes  are  sometimes  involved  as  illustrated  in  Fig. 
74.  Occasionally  the  vesicles  become  very  large  and  develop  into  bul- 
lae (varicella  bullosa)  and  in  certain  severe  cases  cutaneous  ecchy- 
moses  and  bleeding  from  the  mucous  membranes  occur  (varicella 
hemorrhagica). 

In  delicate  and  especially  in  tubercular  children  the  lesions  may 
become  gangrenous  and  large  areas  of  skin  may  be  destroyed.    The 

87 


gangrenous  spots  are  usually  circular  in  shape,  and  as  a  rule  they 
vary  from  a  quarter  to  three-quarters  of  an  inch  in  diameter.  They 
have  clear  cut  vertical  edges  and  appear  as  though  a  piece  of  skin 
had  been  removed  by  a  small  cutaneous  punch.  The  disease  may 
recur,  as  many  as  three  attacks  having  been  reported  in  the  same 
individual. 

Diagnosis 

This,  in  typical  cases,  occurring  in  children,  presents  but  few  diffi- 
culties, but  in  severe  cases  in  adults  it  is  likely  to  be  mistaken  for 
variola  or  varioloid.  The  principal  differential  points  are  the  short- 
ness and  comparative  mildness  of  the  prodromal  symptoms,  the  rela- 
tively larger  number  of  lesions  on  the  trunk,  especially  on  the  back, 
the  absence  of  infiltration  In  the  lesions,  their  sui^erficial  character, 
the  rapid  development  of  the  lesions  from  papules  to  pustules,  their 
development  in  crops,  and  lastly,  the  intermingling  of  papules,  ves- 
icles, pustules,  and  crusts  on  the  same  area. 

Prognosis 

This  is  always  favorable  even  in  severe  cases  in  adults. 

Treatment 

Entirely  symptomatic.  If  there  is  much  elevation  of  temperature, 
the  patient  should  be  put  on  liquid  diet  and  kept  in  bed  for  a  few 
days.  A  single  good  dose  of  castor  oil  or  repeated  small  doses  of  calo- 
mel with  sodium  bicarbonate  may  be  given.  If  there  are  many  vesi- 
cles on  the  face,  efforts  should  be  employed  to  prevent  subsequent 
pitting. 

External  applications  of  alcohol  may  be  used  for  its  drying  effect 
on  the  papules  and  protective  dressings  similar  to  those  recommended 
in  variola  may  be  used  to  prevent  the  scratching  and  the  secondary 
infection  which  is  invariably  the  cause  of  the  pits. 


Fig.  74.     Model  in  the  Cliildren's  Clinic  of  Gehcimrat  Heubner  in  Berlin 

{Kolbow). 

Fig.  77.  Model  in  Neisser's  Clinic  in  Breslau  (Kroener).  The  patient, 
forty-three  years  of  age,  was  taken  ill  five  days  previously,  with  high 
temperature  and  severe  general  symptoms.  The  case  was  established 
as  genuine  by  the  fact  of  the  attending  physician  being  attacked  by 
typical  chickenpox. 

Fig.  78.     Model  in  Lesser's  Clinic  in  Berlin  (Kolbow). 

88 


Plate  51. 


.5 
'B 

'o 

u 

> 

O 

00 


Vaccinia 

Plate  51,  Figs.  79  and  80 

This  is  the  term  applied  to  the  exanthem  produced  by  the  inocula- 
tion of  bovine  virus.  On  the  second,  third  or  fourth  day  after  vac- 
cination there  appears  at  the  site  of  inoculation  a  slightly  elevated 
papule,  surrounded  by  a  reddish  zone.  This  papule  becomes  vesicular 
on  the  fifth  or  sixth  day,  and  reaches  its  maximum  size  on  the  eighth 
day  when  it  is  a  large,  tense,  umbilicated  vesicle  one  fourth  to  one 
half  of  an  inch  in  diameter  with  a  hard  and  prominent  margin,  filled 
with  a  limpid  fluid  and  surrounded  by  a  wide  inflammatory  areola. 
Its  development  is  accompanied  by  general  malaise,  fever,  tempera- 
ture, 101°  to  104°  F.,  which  usually  lasts  four  or  five  days,  and  swell- 
ing and  soreness  of  adjacent  lymphatic  glands.  After  the  tenth  day 
the  vesicle  begins  to  desiccate  and  by  the  fourteenth  day  is  covered 
by  a  thick,  firm  crust,  which  falls  off  after  a  period  of  from  one  to 
three  weeks,  leaving  a  sharply  defined  pitted  or  honeycombed  scar. 
Constitutional  sjTnptoms  are  less  severe  in  children  under  one  month 
than  in  those  of  five  or  six  months ;  and  infants  should  be  vaccinated 
as  soon  as  nutrition  is  established,  usually  in  the  first  three  months. 
As  a  rule  it  should  be  avoided  during  dentition. 

Generalized  vaccinia  may  be  either  local  or  constitutional.  The 
former  is  due  to  repeated  inoculations,  the  vaccination  repeating  it- 
self at  each  point  of  inoculation.  It  is  seen  especially  on  the  face  and 
genitals ;  and  sometimes  there  is  an  outbreak  of  lesions  over  the  whole 
body,  accompanied  by  severe  constitutional  s>inptoms.  This  type  is 
usually  seen  in  the  second  or  third  week.  In  constitutional  general- 
ized vaccinia,  vesicles  are  frequently  seen  in  the  neighborhood  of  the 
primary  sore,  but  the  true  generalized  vaccinia  of  systemic  origin, 
with  lesions  developing  on  different  parts  of  the  body,  is  rare.  The 
lesions  are  most  numerous  on  the  vaccinated  limb ;  they  may  be  few 
or  many.  Each  lesion  pursues  the  course  of  the  typical  primary  vac- 
cination. The  vesicles  usually  develop  from  the  eighth  to  the  tenth 
day,  and  they  may  continue  to  develop  in  crops  for  five  or  six  weeks 

89 


after  vaccination.    Generalized  vaccinia  has  occurred  in  children  fol- 
lowing the  ingestion  of  powdered  crusts  from  a  vaccination  lesion. 

Diagnosis 

The  history  of  a  recent  vaccination  should  render  the  diagnosis 
easy  even  in  complicated  cases. 

Prognosis 

Constitutional  symptoms  associated  with  generalized  vaccinia  in 
children  may  be  very  severe,  and  deaths  have  been  reported,  but  ordi- 
narily the  prognosis  is  favorable. 

Prophylaxis 

Delicate  children  and  infants  in  poor  health  should  not  be  vac- 
cinated until  their  general  condition  has  been  improved  and  children 
suffering  from  itchy  skin  diseases  as  eczema,  urticaria  or  scabies 
should  not  be  vaccinated  until  the  eruption  is  quite  cured.  Vaccina- 
tion pustules  should  be  covered  by  a  dressing  or  shield  so  that  the 
child  is  unable  to  scratch  or  pick  it. 

Treatment 

There  are  seldom  any  indications  for  internal  medication.  The 
affected  areas  should  be  covered  with  wet  compresses.  Solutions  of 
boric  acid  or  acetate  of  aluminum  are  the  ones  most  generally  rec- 
ommended. As  the  condition  improves  a  weak  ichthyol  ointment 
may  be  substituted  for  the  wet  dressings. 


Fig.  79.     Model  in  the  K.  K.  Vaccine  Institute  in  Vienna  (Henning). 
Fig.  80.     Model  in  Finger's  Clinic  in  Vienna  {Henning). 

90 


Plate  52. 


J3 
O 


00 


00 


Morbilli 

Synonyms:    Measles,  Rubeola 
Plate  52,  Figs.  81  and  82 

Tliis  is  an  acute  contagious  eruptive  fever  of  unknowTi  causation. 
The  period  of  incubation  is  from  ten  to  fourteen  days,  but  may  be 
as  long  as  eighteen  or  twenty  days.  The  disease  begins  with  catarrhal 
symptoms — sneezing,  coughing,  injection  of  the  conjunctiva,  lacryma- 
tion  and  rise  of  temperature  to  about  103°  F. 

On  the  second  day  usually  there  appear  on  the  buccal  mucous  mem- 
brane and  inside  of  the  lips  small  irregular  spots  of  a  bright  red  color. 
In  the  centre  of  each  spot  is  a  minute  bluish  white  speck.  They 
lose  their  characteristic  appearance,  however,  as  the  eruption  on  the 
skin  develops.  These  are  the  Koplik  spots  and  are  of  considerable 
diagnostic  value. 

As  a  rule  on  the  fourth  day  the  eruption  appears — first  on  fore- 
head and  cheeks  in  the  form  of  small  red  maculo-papules  which 
increase  in  size  and  spread — the  whole  body  being  covered  in  twenty- 
four  to  forty-eight  hours.  The  rash  when  fully  developed  consists  of 
roundish,  slightly  elevated  maculo-papules  which  vary  in  size  from 
a  pinhead  to  a  finger  nail,  varying  in  color  from  a  dark  red  to  a 
purplish  hue.  They  are  frequently  confluent  on  both  the  face  and 
body,  and  have  often  been  erroneously  diagnosed  as  a  mixed  infection 
of  scarlatina  and  morbilli.  Hemorrhages  into  tlie  lesions,  especially 
on  the  lower  part  of  the  abdomen  and  thighs,  are  seen  fairly  fre- 
quently but  do  not  add  as  much  to  the  gravity  of  the  disease  as  when 
seen  in  variola  or  scarlatina.  Wliere  the  rash  is  confluent  there  is 
considerable  swelling  of  the  skin.  The  eruption  begins  to  fade  after 
two  or  three  days,  leaving  brown  pigmentation  at  the  site  of  the 
lesions,  especially  on  the  trunk  and  limbs. 

The  temperature,  which  reaches  its  greatest  height  with  the  full 
development  of  the  rash,  falls  rapidly  with  the  fading  of  the  rash,  to- 
gether with  a  subsidence  of  the  catarrhal  symptoms. 

91 


The  amount  of  desquamation  varies  with  the  intensity  of  the  rash 
and  may  not  be  seen  at  all  in  mild  cases.  It  usually  occurs  in  fine 
branny  scales  and  is  completed  in  from  fourteen  to  twenty-one  days 
after  the  appearance  of  the  eruption. 

Prognosis 

This  is  favorable  unless  some  serious  complication  develops. 

Prophylaxis 

AU  cases  should  be  properly  isolated  until  desquamation  is 
finished,  and  children  in  a  family  where  a  case  exists  should  be 
excluded  from  school  until  the  case  has  terminated.  Bedding,  carpets, 
etc.,  should  be  disinfected  and  the  premises  fumigated  in  a  manner 
similar  to  that  described  under  variola. 

Diagnosis 

In  a  well  developed  case  this  is  very  easy.  It  is  diagnosed  from 
rubella  by  the  severity  of  the  onset,  its  longer  duration,  the  presence 
of  Koplik's  spots,  coryza  and  conjunctivitis.  The  lesions  of  morbilli 
are  larger  and  deeper  in  color  than  tliose  of  rubella,  and  the  consti- 
tutional symptoms  are  always  more  severe. 

From  scarlatina  it  is  diagnosed  by  the  character  of  the  onset,  its 
longer  duration,  the  presence  of  Koplik's  spots,  the  absence  of  severe 
angina  and  particularly  by  the  character  of  the  eruption,  that  of 
scarlatina  being  a  punctate  erythema. 

Treatment 

Kest  in  bed  in  a  well  ventilated  room  and  liquid  diet  should  be 
insisted  upon  as  long  as  the  temperature  is  elevated  and  the  rash  is 
present.    The  room  should  be  darkened  to  protect  the  eyes. 

Baths  are  generally  agreeable  and  should  be  given  during  the 
stage  of  eruption. 

The  temperature  is  self -limited  and  usually  requires  no  treatment 
beyond  the  baths. 

The  eyes  should  be  kept  clean  with  a  boric  acid  solution. 

If  the  cough  is  very  troublesome  a  few  small  doses  of  heroin  or 
codein  may  be  given. 

Severe  cases  with  cyanosis,  high  fever  and  cold  extremities  should 
have  stimulants — whiskey  and  strychnia.  An  ice  cap  applied  to  the 
head  is  very  agreeable,  and  hot  mustard  baths  are  often  valuable  in 
relieving  pulmonary  congestion. 

92 


Edema  of  the  glottis  occurs  fairly  often  and  may  necessitate  in- 
tubation or  tracheotomj'. 

Membranous  pharyngitis  or  laryngitis  should  be  treated  like 
other  cases  of  pseudo-diphtheria.  If  the  diphtheria  bacillus  is  pres- 
ent, diphtheria  antitoxin  should  be  used  the  same  as  in  a  simple  case 
of  diphtheria. 

After  recovery  tonics  as  iron,  quinia  and  strychnia  are  indicated 
and  to  delicate  children  cod-liver  oil  should  be  given  during  the  fol- 
lowing cold  season. 

The  most  serious  sequela  is  tuberculosis  either  of  the  lungs  or 
cervical  glands  and  this  unfortunately  is  seen  quite  frequently.  A 
number  of  cases  of  lupus  vulgaris  have  been  reported  as  developing 
shortly  after  an  attack  of  morbilli. 


Fig.  81.     Model  in  Schlossmann's  Home   for  Infants,  Dresden    (Kolbou) 
Fig.  82.    Model  in  Neisser's  Clinic  in  Breslau  (Kroener). 

93 


Rubella 

Synonyms:    German  measles,  Rotheln 
Plate  53,  Fig.  83 

Eubella  is  an  acute  contagious  eruptive  fever  with  an  incubation 
period  of  from  ten  to  twenty-one  days.  The  period  of  invasion  is  very 
short,  usually  lasting  only  a  few  hours ;  and  in  ntiany  cases  no  prodro- 
mal symptoms  at  all  occur.  When  they  are  present  they  consist  of 
malaise,  slight  fever,  and  very  mild  catarrhal  symptoms ;  but  there 
may,  very  rarely,  be  vomiting,  convulsions,  delirium,  epistaxis,  rigors 
and  headache. 

The  eruption  appears  first  on  the  face  and,  spreading  rapidly, 
covers  the  whole  body  in  less  than  a  day.  Occasionally  it  comes  out 
first  on  the  back,  or  the  whole  body  may  be  covered  almost  at  once. 
In  many  cases  the  whole  body  is  not  covered,  but  the  rash  is  seen 
most  constantly  on  the  face. 

The  character  of  the  eruption  is  quite  variable.  It  is  most  fre- 
quently composed  of  small  pinkish  maculo-papules  from  a  pinhead  to 
a  pea  in  size,  frequently  confluent  on  the  face,  forming  large  irregular 
blotches.  On  the  trunk  it  is  usually  discrete,  but  there  may  be  a 
uniform  red  blush,  still  the  characteristic  maculo-papules  can  be 
found  on  the  forehead,  wrists  or  fingers.  The  degree  of  elevation  of 
the  lesions  is  variable  from  being  almost  imperceptible  to  being  so 
marked  as  to  give  the  skin  a  distinctly  shotty  feel.  The  color  also 
may  vary  from  pink  to  a  dark  red  and  very  rarely  the  rash  may  be 
hemorrhagic. 

Minute  bright  red  points  may  be  seen  on  the  uvula  and  soft  palate 
during  the  first  twenty-four  hours. 

The  temperature  is  highest  with  the  full  development  of  the  rash, 
and  is  101°  F.  or  less,  but  in  the  very  rare  severe  cases  it  may  be 
103°  F. 

The  rash  is  generally  of  two  or  three  days'  duration  and  is  usually 
accompanied  by  moderate  itching.  The  post  cervical  glands  are 
always  enlarged.    They  subside  slowly  without  suppuration. 

94 


Plate  5: 


Fig.  83.  Rubeola. 


Desquamation  may  be  entirely  wanting  but  usually  occurs  in  the 
form  of  fine  scales. 

Diagnosis 

Rubella  is  diagnosed  from  morbilli  by  its  longer  period  of  incuba- 
tion— shorter  period  of  invasion — absence  of  Koplik's  spots  and  its 
milder  catarrhal  and  constitutional  sjTnptoms. 

From  scarlatina,  by  the  absence  of  severe  prodromal  symptoms — 
the  absence  of  angina — the  presence  of  the  typical  maculo-papules  on 
the  forehead,  wrists  or  fingers — and  its  longer  period  of  incubation. 

In  all  cases,  unless  the  disease  is  epidemic,  it  is  not  safe  to  make 
the  diagnosis  of  rubella  until  the  case  has  been  under  observation  for 
some  time. 

Treatment 

This  is  entirely  symptomatic.  A  dose  of  calomel  or  castor  oU 
at  the  beginning  of  the  attack  is  practically  all  the  medication  re- 
quired.   The  patient  should  be  isolated  for  about  a  week. 


Fig.  83.    Model  in  Neisser's  Clinic  in  Breslau  {Kroener). 

95 


Scarlatina 

Synonym:    Scarlet  fever 
Plate  54,  Fig.  84;  Plate  55,  Fig.  85 

Scarlatina  is  an  acute  contagious  disease  of  unknown  causation. 
It  has  been  claimed  that  a  streptococcus  is  the  causative  agent,  but 
while  this  is  associated  with  the  complications,  it  is  probably  but  a 
secondary  or  accompanying  infection.  The  disease  most  frequently 
attacks  children  between  two  and  ten  years  of  age.  Adults  are  less 
susceptible  than  children.  Scarlatina  is  not  as  contagious  as  measles. 
Frequently  only  one  child  in  a  family  where  there  are  several  children 
will  contract  the  disease,  while  with  measles  practically  all  children 
exposed,  unless  protected  by  a  previous  attack,  contract  the  disease. 

The  period  of  incubation  is  usually  from  two  to  six  days,  but  it 
may  be  as  short  as  six  hours  or  as  long  as  two  weeks;  over  seven 
days,  however,  is  extremely  rare.  The  onset  is  sudden,  with  a  rise 
of  temperature  from  101°  to  105°  F.,  vomiting,  sore  throat  and 
frequently  in  children,  convulsions  and  delirium,  the  intensity  of 
the  symptoms  varying  with  the  severity  of  the  attack.  The  vomiting 
is  frequently  persistent  and  without  nausea.  The  throat  symptoms 
may  be  so  mild  that  they  are  only  detected  by  examination,  but  in 
most  cases  there  is  a  uniform  redness  of  the  whole  pharynx,  and  small 
red  points  are  seen  on  the  hard  palate  and  the  patient  complains  of 
soreness  and  pain  on  swallowing.  The  tip  and  edges  of  the  tongue 
are  red  and  the  centre  is  covered  with  a  thick  fur,  through  which  the 
enlarged  papillae  project,  giving  it  the  so-called  strawberry  appear- 
ance. In  severe  cases  the  tonsils  and  fauces  are  markedly  swollen  and 
may  be  covered  by  a  pseudo-membrane,  which  may  extend  from  the 
posterior  wall  into  the  mouth  or  up  into  the  nostrils  and  occasionally 
may  involve  the  larynx,  trachea  and  bronchi.  The  cervical  glands  are 
frequently  enlarged  and  tender. 

The  eruption  usually  appears  on  the  second  day,  but  it  may 
develop  within  twelve  hours,  or  it  may  be  delayed  until  the  fourth  or 
fifth  day.    It  appears  first  on  the  neck  and  chest  and  spreads  rapidly, 

96 


Plate  54 


Fig.  84.  Scarlatina. 


involving  the  entire  skin,  in  from  fonr  to  twenty-four  hours.  It  has  a 
vivid  scarlet  hue  and  is  conii)()sed  of  innumerable  minute  red  points 
upon  an  erytliematous  ground.  Although  seen  upon  the  face  there  is 
a  peculiar  pallor  around  the  mouth.  Occasionally  all  of  the  skin  is 
not  involved,  the  rash  occurring  in  patches,  or  the  rash  may  not 
develop  on  the  face,  or  it  may  be  present  only  on  certain  parts, 
usually  the  groins,  axilla;,  flexures  of  the  elbows,  or  upon  the  buttocks 
and  posterior  surface  of  the  thighs.  In  some  cases  it  is  so  slight 
and  evanescent  that  it  entirely  escapes  observation,  or  it  may  be 
entirely  absent  both  in  mild  cases  and  in  those  with  severe  angina, 
and  even  in  malignant  cases  it  may  never  develop.  Miliary  vesicles 
are  frequently  seen,  especially  upon  the  chest  and  abdomen.  Petechias 
are  occasionally  seen  and  in  malignant  cases  they  become  very  exten- 
sive. At  the  height  of  the  eruption,  the  skin  of  the  face  and  hands 
may  be  considerably  swollen.  Pruritus  is  variable,  and  at  times  may 
be  quite  marked.  The  rash  may  last  from  a  few  hours  to  about 
six  days. 

The  temperature  is  highest  with  the  full  development  of  the  rash 
and  in  fatal  cases  may  rise  to  108°  or  even  109°  F.  The  pulse  varies 
from  120  to  150  or  higher.  In  favorable  cases  it  continues  high  for 
two  to  five  days  and  falls  by  lysis.  The  vomiting  usually  stops  with 
the  development  of  the  rash.  The  urine  shows  febrile  characters  and 
albuminuria  is  frequent.  The  tongue  desquamates  in  a  few  days  and 
is  clean  by  the  time  the  rash  begins  to  fade.  The  desquamation  of  the 
skin  is  characteristic.  It  begins  after  the  rash  has  faded,  usually  on 
the  eighth  to  twelfth  day,  but  may  be  delayed  until  the  twenty-first 
day.  It  begins  on  the  neck  and  chest  and  is  flaky  in  character.  On 
the  hands  and  feet,  where  the  epidermis  is  thickest,  it  is  finislied  last, 
and  here  the  flakes  are  quite  large,  frequently  the  epidermis  being 
shed  almost  entirely  in  a  glovelike  cast.  It  is  usually  completed  at 
the  end  of  thirty-five  days,  but  may  continue  for  seven  or  eight  weeks. 

Diagnosis 

Typical  cases  present  no  difficulty;  but  in  the  mild  and  atypical 
ones  the  diagnosis  is  extremely  difficult  and  at  times  impossible  until 
the  characteristic  desquamation  appears.  The  principal  diagnostic 
symptoms  are  the  vomiting  associated  with  sore  throat,  and  a  punc- 
tate rash  on  the  hard  palate.  The  pulse-temperature  ratio  in  mild 
cases  is  also  a  valuable  aid.  The  pulse  is  practically  always  increased 
out  of  proportion  to  the  temperature.  The  groins,  axilla  and  anterior 
surfaces  of  clhows  should  be  carefully  examined  for  a  punctate  rash. 

97 


From  morbilli,  scarlatina  is  differentiated  by  its  shorter  prodro- 
mal period,  the  absence  of  coryza  and  conjunctivitis  and  especially 
by  the  absence  of  Koplik's  spots. 

From  rubella  it  is  distinguished  by  the  comparatively  mild  symp- 
toms of  rubella,  even  with  a  widely  distributed  and  well  marked  rash ; 
such  a  rash  in  scarlatina  invariably  causing  a  temperature  of  102° 
to  103°  F. 

The  scarlatina  type  of  rashes  produced  by  belladonna,  quinia  and 
occasionally  antipyrine  are  not  associated  with  intense  constitutional 
symptoms — the  temperature  is  not  much  elevated  if  at  all — and  the 
scarlet  angina  is  lacking. 

In  erythema  scarlatiniforme  the  fauces,  though  red,  are  not  swol- 
len, the  strawberry  tongue  is  absent  and  the  rash  is  frequently 
localized.  Desquamation  begins  about  the  third  or  fourth  day  and 
is  usually  quite  profuse  while  the  rash  is  still  present. 

Prognosis 

The  "mortality  of  scarlatina  varies  in  different  epidemics;  it  is 
highest  in  children  under  five  years  of  age.  The  general  average  of 
all  ages  is  about  twelve  to  fourteen  per  cent. 

In  individual  cases,  even  in  the  mild  ones,  a  guarded  prognosis 
must  be  given  on  account  of  the  serious  complications  which  may 
develop  during  the  course  of  the  disease. 

Treatment 

All  cases,  even  the  mildest,  must  be  kept  in  bed  for  at  least  three 
weeks,  and  during  this  period  the  diet  should  consist  entirely  of  milk. 
The  temperature  usually  needs  no  special  care,  but  if  hyperpyrexia 
exists,  hydrotherapy  gives  the  best  results.  For  the  relief  of  the  rest- 
lessness, an  ice  bag  to  the  head  and  an  occasional  dose  of  phenacetin 
are  usually  satisfactory. 

The  sore  throat  is  frequently  very  annoying.  Irrigations  with  hot 
normal  salt  solution  or  spraying  with  equal  parts  of  hydrogen  per- 
oxide and  lime  water  affords  considerable  relief.  An  ice  collar  around 
the  neck  is  often  very  agreeable  to  the  patient. 

Careful  watch  must  be  kept  upon  the  ears,  as  frequently  an  otitis 
or  even  mastoiditis  may  develop  without  being  accompanied  by  pain. 
The  drum  membrane  should  be  incised  as  soon  as  it  is  found  to  be 
congested  and  bulging.  When  the  symptoms  of  mastoid  involvement 
develop  an  early  operation  is  advisable. 

The  heart  also  must  be  watched  carefully  and  as  soon  as  the  pulse 

98 


is  rapid  or  irregular  or  the  first  sound  of  the  heart  is  altered,  stimu- 
lants should  be  used,  such  as  digitalis,  strophanthus,  strychnia  and 
whiskey.  Whiskey  is  especially  indicated  in  septic  cases  Avith  severe 
angina  and  adenitis.  The  patient  should  be  kept  in  bed  until  the  pulse 
rate  is  practically  normal. 

The  urine  should  be  examined  frequently  during  the  first  three 
weeks.  To  prevent  the  development  of  nephritis  the  diet  should  be 
milk  for  at  least  three  weeks;  the  patient  should  be  encouraged  to 
drink  plenty  of  water — weak  lemon  or  orangeades  are  very  agree- 
able and  can  be  allowed.  The  bowels  should  be  kept  open  -wdth  salines 
and  an  occasional  dose  of  calomel  or  gray  powder.  If  nephritis 
develops  it  should  be  treated  as  a  nephritis  from  any  other  cause. 

As  soon  as  desquamation  begins,  the  patient  should  be  given  daily 
baths  to  assist  the  process.  If  oils  are  used  they  should  not  be 
carbolized,  owing  to  the  danger  of  absorption. 

Adenitis  should  be  treated  by  ice  bags  or  strong  iehthyol  oint- 
ments.   As  soon  as  pus  is  detected,  it  should  be  evacuated. 

For  the  arthritis  immobilization  of  the  affected  joints,  with  aspirin 
or  salicin  internally.  If  pus  forms,  the  joints  must  be  freely  opened. 
The  treatment  of  this  complication  with  a  mixed  streptococcus  vac- 
cine has  not  been  very  satisfactory,  but  recently  good  results  have 
been  reported  from  the  emploATnent  of  a  serum  prepared  from  dif- 
ferent strains  of  streptococci. 

The  secondary  anemia  calls  for  tonics,  especially  iron  and  digi- 
talis.   Basham's  Mixture  is  a  pleasant  and  efficient  form  of  iron. 


Fig.  84.    Model  in  Neisser's  Clinic  in  Breslau  (Kroener). 
Fig.  85.     Model  in  Schlossmann's  Home  for  Infants,  Dresden  {Kolbow). 

99 


Erysipelas 

Synonym:    St.  Anthony's  Fire 
Plate  55,  Fig.  86 

Erysipelas  is  an  acute  inflammatory  disease  of  the  skin  and 
sub-cutaneous  tissues  caused  by  the  streptococcus  (erysipelatous) 
pyogenes.  After  prodromal  symptoms  of  from  four  to  forty-eight 
hours'  duration,  consisting  of  malaise,  chills,  moderate  fever  and 
occasionally  anorexia  and  vomiting,  there  appear  at  the  site  of 
infection  one  or  more  erythematous  spots.  These  spots  rapidly 
increase  in  size,  forming  a  large,  tense,  red,  shining  patch,  the  tem- 
perature of  which  is  higher  than  that  of  the  normal  skin.  Its  outline 
is  usually  irregular,  but  it  is  very  sharply  defined  and  its  border  is 
raised.  Its  size  may  be  limited  to  a  patch  only  a  few  inches  in  diam- 
eter, or  it  may  involve  large  areas  of  the  skin.  As  the  process  devel- 
ops the  color  becomes  a  dark,  angry  red,  the  swelling  increases  and 
vesicles  and  buUge,  filled  with  a  clear  yellow  serum,  may  develop. 
The  amount  of  swelling  depends  on  the  intensity  of  the  inflammatory 
process  and  on  the  structure  of  the  subcutaneous  tissues ;  where  there 
is  much  loose  areolar  tissue,  it  is  often  very  considerable. 

Subjective  symptoms  are  moderate  pruritus,  burning,  tenderness 
and  more  or  less  pain.  The  rash  reaches  its  height  in  about  a  week, 
remains  stationary  for  a  day  or  so  and  gradually  subsides,  together 
with  a  gradual  improvement  in  the  constitutional  symptoms,  which 
have  consisted  of  those  of  an  acute  febrile  disturbance  from  tox- 
aemia— temperature  103°  to  105°  F.,  headache,  pain  in  the  limbs,  loss 
of  appetite,  coated  tongue  and  nausea  and  vomiting,  etc. 

The  whole  process  may  be  very  mild — the  skin  showing  only  an 
erythematous  area  with  very  little  swelling  and  no  vesicles  or  bullfp, 
accompanied  by  mild  constitutional  symptoms.  Occasionally  in 
severe  cases  the  vesicles  and  bullae  may  be  hemorrhagic.  In  some 
people  who  are  peculiarly  susceptible,  erysipelas  may  recur  fre- 
quently for  a  long  period  of  time  and  by  obstruction  of  the  lymphatics 

100 


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lead  to  elophantiasis.    The  hair  is  usually  lost  after  erysipelas  of  the 
head  and  the  alopecia  resembles  that  of  syphilis. 

Complications 

Secondary  infection  by  staphylococci  may  cause  extensive  sup- 
purative cellulitis.  Superficial  abscesses  occur  frequently  during 
convalescence. 

The  most  serious  complications  arise  from  the  spreading  of  the 
disease  to  the  mucous  membrane  of  nose,  mouth,  pharjnix,  larynx, 
rectum  or  vagina. 

Prognosis 

This  should  always  be  guarded.  In  extensive  cases  in  the  very 
young  or  in  those  debilitated  by  alcoholic  excesses  and  exposure,  the 
outlook  is  not  favorable.  A  sudden  rise  of  the  temperature,  after 
it  has  once  subsided,  means  either  another  outbreak,  or  the  develop- 
ment of  a  serious  complication. 

Diagnosis 

An  erythematous  eczema  is  not  accompanied  by  so  much  swelling, 
and  never  has  the  characteristic  shining  appearance  of  erysipelas. 
The  line  of  demarcation  between  the  affected  and  unaffected  portions 
of  the  skin  is  usually  ill  defined  in  eczema.  AVhen  occurring  upon  the 
face,  the  scalp  is  usually  spared,  while  an  erysipelas  tends  to  involve 
the  scalp. 

Erysipeloid  of  Rosenhach,  which  as  a  rule  occurs  only  on  the 
fingers  and  hands,  is  characterized  by  much  milder  local  reaction  and 
the  almost  entire  absence  of  constitutional  symptoms. 

From  the  so-called  pseudo-erysipelas  that  is  secondary  to  intra- 
nasal inflammation  erysipelas  is  distinguished  by  the  severity  of  its 
constitutional  symptoms,  its  tendency  to  spread  widely  beyond  the 
nose  and  its  adjacent  tissues  and  the  absence  of  history  of  a  long 
continued  nasal  trouble. 

Angioneurotic  edema  does  not  present  the  glazed  shiny  surface  of 
erysipelas  and  is  not  accompanied  by  symptoms  of  toxemia.  It  occurs 
in  successive  and  recurrent  attacks  and  is  often  accompanied  by 
rheumatoid  pains. 

Treatment 

Best  in  bed  during  the  whole  course  of  the  disease.  Isolation  as 
in  scarlatina  or  measles.    The  diet  should  be  liquid  and  supporting. 

101 


Stimulants  are  frequently  necessary.  It  has  long  been  the  custom  to 
prescribe  large  and  frequently  repeated  doses  of  the  tincture  of  iron, 
but  it  is  doubtful  if  this  treatment  is  of  much  value.  Quinia  and 
antipyrine  are  sometimes  of  service  in  lowering  the  general  tempera- 
ture. The  treatment  by  antistreptococcus  serums  has  not  been  very 
satisfactory  in  practice  although  theoretically  it  seemed  quite  prom- 
ising. The  affected  areas  should  be  covered  Avith  wet  dressings  of 
alcohol,  aluminum  acetate,  lead  and  opium  wash,  or  ichthyol  in  a 
twenty  to  fifty  per  cent,  aqueous  solution.  A  favorite  application 
formerly  much  used  at  the  New  York  City  Hospital  was  the  saturated 
solution  of  magnesium  sulphate.  Sdbouraud}  recommends  colloidal 
silver  as  a  local  application. 


'  Sabouraud:  Regional  Dermatology.     Rebman  Company,  141-145  West 
Thirty-sixth  Street,  New  York.     New  Edition,  $3.00. 


Fig.  86.    Model  in  Riehl's  Clinic  in  Vienna  (^Herming). 

102 


Plate  56. 


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Exfoliatio  Areata  Linguae 

Synonyms:    Pityriasis   linguae,  Transitory   bonign   plaques   of   the    tongue. 

Geographical   tongue. 

Plate  56,  Fig.  87 

This  affection  is  a  peculiar  arrangement  of  the  normal  coating  of 
the  tongue  which  has  received  various  designations  and  has  been 
explained  in  many  ways.  It  has  been  looked  upon  in  some  quarters  as 
a  glossitis,  even  of  an  ulcerated  kind ;  in  others  as  a  simple  desquama- 
tion or  exfoliation.  It  has  been  regarded  as  a  manifestation  of  syph- 
ilis. Since  it  has  been  seen  in  nurslings,  several  causal  factors  are 
thereby  eliminated,  as  for  example  dependence  on  dentition. 

The  pediatrist  Czerny  has  perhaps  thrown  some  light  upon  the 
condition  by  making  it  an  expression  of  the  exudative  diathesis.  This 
makes  it  hereditary,  at  least  in  its  predisposition.  It  may  also  be 
looked  upon  as  a  permanent  peculiarity  dependent  for  its  manifesta- 
tions on  accidents — dietetic  peculiarities.  It  often  improves  under  a 
strict,  bland  diet.  The  geographical  tongue,  in  other  words,  is  made 
much  worse  by  the  same  dietetic  factors  which  cause  acute  indigestion 
and  diarrhea.  But  aside  from  the  exudative  diathesis  and  improper 
or  excessive  eating,  numerous  other  factors  may  be  isolated,  as 
neuropathy,  climate,  mechanical  irritation. 

The  appearance  of  a  geographical  tongue  is  quite  characteristic. 
The  tongue  is  the  seat  of  plaques  of  a  lively  red  color,  varying  much 
in  size  and  shape.  They  are  chiefly  rounded,  however,  and  very 
slightly  prominent.  The  papillae  in  these  areas  appear  enlarged.  At 
the  border  of  the  plaques  is  a  narrow,  gray,  stippled  areola.  In  some 
instances  the  border  has  a  distinct  double  contour.  The  stippling  is 
simply  the  filiform  papillae,  rendered  conspicuous  because  broadened 
and  surmounted  by  thickened  epidermis.  These  papillae  are  also  uni- 
formly enlarged  in  other  parts  of  the  tongue,  which  present  thereby 
a  grain  leather  appearance.  Although  the  condition  is  spoken  of  as 
a  permanent  one,  individual  plaques  show  great  volatility.    Even  be- 

108 


fore  the  end  of  tliirty-six  hours  they  may  have  run  through  their  cycle 
and  vanished,  as  new  plaques  appear.  The  process  has  therefore 
been  likened  to  the  alteration  of  patterns  in  a  kaleidoscope. 

Diagnosis 

The  affection  has  no  doubt  been  confounded  with  Mdller's  glos- 
sitis and  mucous  patches  of  syphilis.  The  greatest  confusion  would 
be  likely  to  arise  if  some  other  affection  acted  as  an  exciting  cause  to 
geographical  tongue — syphilis,  for  example. 

Treatment 

There  is  no  treatment  to  be  actually  directed  against  this  condi- 
tion per  se.  The  individual  may  be  treated  to  restore  him  to  physio- 
logic equilibrium,  and  the  various  local  applications  used  in  mild 
stomatitis  seem  to  be  indicated  on  general  principles. 


Fig.  87.     Model  in  St.  Louis  Hospital  in  Paris,  No.  2235  (Baretta). 
Meureman  and  Ramond's  case. 

104 


Leukoplakia 

Plate  56,  Fig.  88 

Clmieally,  leukoplakia  is  represented  by  smooth,  milk-wliite  spots 
which  at  first  are  of  a  pale  rose  tint  and  not  well  differentiated  from 
the  outlying  mucosa.  They  become  pure  white,  and  sometimes  even- 
tually bluish  or  pearly.  Eventually  they  become  shariily  differen- 
tiated at  the  borders,  the  more  so  because  often  surrounded  by  a 
bright-red  areola.  The  thickened  epidermis,  becoming  harder  with 
time,  is  eventually  detached,  and  when  they  come  away  leave  a  shal- 
low or  deep  fissure.  That  an  ulcer  does  not  develop  is  due  to  the 
peculiar  narrow  shape  of  the  original  lesion.  The  white  color  may 
become  dark — yellowish  or  brownish — from  minute  hemorrhages. 
Some  of  the  lesions  have  almost  a  cartilaginous  hardness  and  thick- 
ness. The  mucous  membrane  beneath  these  thickenings  is  rich  in 
blood-vessels,  which  are  permeated  with  leucocytes.  The  papilla  are 
elongated  and  increased  in  number. 

In  a  tjT)ical  case  we  encounter  a  number  of  lesions  on  the  anterior 
portion  of  the  dorsum  of  the  tongue ;  and  if  the  case  is  chronic  we  may 
see  side  by  side  spots  in  all  stages  of  development  with  fissures  left 
by  former  spots.  The  tip  and  borders  are  involved  in  the  affected 
area.  The  most  favorite  locality  is  the  inner  aspect  of  the  cheeks. 
where  a  triangular  area  is  implicated.  Fissures  seem  to  be  almost 
peculiar  to  the  tongue. 

An  extraordinary  feature,  when  we  bear  in  mind  the  amount  of 
discomfort  caused  by  various  kinds  of  sore  mouth,  is  the  relative 
absence  of  subjective  symptoms  in  a  large  percentage  of  cases.  It 
often  happens  that  the  presence  of  leukoplakia  is  discovered  by  mere 
accident.  The  subjective  sensations  may  consist  of  nothing  beyond  a 
numb  or  foreign  body  sensation — the  latter  due  in  part  to  the  thick- 
ened areas  in  the  act  of  separation. 

Etiology 

The  affection  is  extremely  chronic  and  confined  almost  entirely 
to  males,  who  are  seldom  attacked  before  the  age  of  forty.    It  ap- 

105 


pears  to  result  from  the  cooperation  of  a  number  of  causes.  The 
most  common  association  is  antecedent  syphilis  and  tobacco-smoking, 
but  these  only  furnish  a  predisposition. 

Diagnosis 

There  is  a  notable  resemblance  to  the  mucous  patches  of  syphilis, 
which  are  first  white  and  then  succeeded  by  raw  surfaces.  As  a  rule, 
leukoplakia  spots  are  much  more  numerous  and  prominent.  Mucous 
patches  are  usually  seen  at  the  sides,  tip  and  under  surface  of  the 
tongue.  They  come  and  go  within  a  short  interval,  while  leukoplakia 
is  extremely  chronic,  lasting  for  years,  and  having  little  tendency  to 
recovery.  The  fissures  which  result  might  be  confused  with  later 
syphilitic  disease.  The  crucial  test  is  the  result  of  treatment,  which 
is  principally  negative  in  leukoplakia. 

Prognosis 

This  is  not  particularly  good  for  recovery  and  the  affection  must 
be  looked  upon  as  a  serious  one  when  we  consider  that  it  is  a  not  un- 
common forerunner  of  cancer. 

Treatment 

All  sources  of  irritation  must  be  removed.  Sharp  teeth  which  rub 
against  lesions  should  be  filed  do\\Ti  and  all  carious  teeth  either  filled 
or  extracted.  Tobacco  and  all  pungent  food  articles  and  the  taking 
of  hot  foods  and  drinks  must  be  proscribed.  For  inveterate  smokers 
a  very  moderate  indulgence  may  be  permitted.  Mouth  washes  must 
be  used  freely  and  may  be  alternated.  Hydrogen  peroxide  seems  to  be 
the  best  suited,  an(^  any  mild  astringent  solution  may  be  employed. 
For  actual  treatment  to  produce  permanent  results  various  mild  caus- 
tics are  used,  the  strength  to  be  gradually  increased.  The  very 
number  of  these  in  use  goes  to  show  the  lack  of  a  dependable  remedy 
— silver  nitrate,  chromic  acid,  lactic  acid,  salicylic  acid,  etc.,  etc. 
Occasionally  cases  are  benefited  by  injections  of  salvarsan.  Some 
surgeons  recommend  the  removal  of  the  entire  epithelial  coating  with 
curette  or  cautery,  but  it  is  not  certain  that  the  results  warrant  such 
measures. 


Fig.  88.     Model  in  St.  Louis  Hospital  in  Paris,  No.  1573  (Baretta). 

Fournier's  case. 

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-L'TV 


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